La verdad sobre cómo convertirse en un gran médico (nadie enseña esto), con el Dr. Ricardo Estape

Introduction

Dr. de la Cruz-Muñoz: Listen, I've admired your work for a long time. We've known each other forever. We finished medical school within a few years of each other, so I've been watching your career and watching you grow and develop for a long time. Besides the incredible skill that you're famous for, what has really impressed me is your ability to build trust with patients and colleagues. So this is what I want the conversation to be about: your journey, how you got here, and the things that people don't normally hear about. Briefly, tell me a little bit about what you do. Not just the CV, but the purpose behind what you do.

The Mentor Who Shaped His Career

Dr. Estape: To me, I got into this really to take care of patients. During med school and residency in particular, there are people that you follow who sort of guide your career. There was a mentor I had back at the University of Pennsylvania and then here at Miami by the name of Sterling Sidler. She was a gyn oncologist, and she was one of these people who would spend hours and hours taking care of patients. We would round sometimes until midnight seeing patients. Granted, I don't want to do that, but she had this connection with patients going through the worst part of their life. They get diagnosed with cancer, then they have to think about chemo, and young women have to figure out what to do about having children.

I already loved taking care of patients, but she instilled this ability not just to connect with these patients, but also to move on and be able to do something for them. When we first started, things like ovarian cancer were a death sentence. Cervical cancer, because of where we are in Miami, was a lot of times a late diagnosis and a death sentence as well. But we were able to get to a point where we could get education out, find these women, and treat them and cure them. Not just control them, but cure them, with some of the advances we've made over the years.

Dr. de la Cruz-Muñoz: That's spectacular. And you first met her when you were a medical student or a resident?

Dr. Estape: When I was a first-year resident. She was a fellow, and she was having problems because as a fellow you have to publish papers, and all she did was take care of patients. She didn't even know how to write a paper, and I had already published some papers. So I said, "Let me help you out." By the time I finished my residency and she finished her fellowship, we had about eight papers published together. It worked really well. That was how we connected, and then I connected into the specialty. I always thought I was going to do oncology of some kind, and this was the perfect specialty for me because I get to do surgery, I get to do oncology. It's not just one thing or the other. You get the combination of everything.

Dr. de la Cruz-Muñoz: What drew you into oncology originally?

Dr. Estape: I have a strong family history of cancer. Prostate cancer: my dad, my uncles, my grandfathers. My family is BRCA positive. My aunt and my mom have had breast cancer, and both have unfortunately passed away from it. It was just a lot of cancer I was exposed to early on, so I always knew I was going to do something in oncology.

From Electrical Engineering to Medicine

Dr. de la Cruz-Muñoz: And when did you decide you wanted to become a surgeon?

Dr. Estape: It's funny you ask that. I actually thought I was going to be an engineer. My bachelor's is in electrical engineering and my master's is in biomedical engineering. I worked for about three or four months with Johnson & Johnson. At Penn, your first year of biomedical engineering is with the medical students.

It's a funny story. I was working in Trenton, New Jersey, with Johnson & Johnson, and I had done all these great improvements on their dialysis machine. I thought I was going to be the hero. So I go in and sit with these engineers, and the guy looks at me and says, "Son, if I put all this technology into this machine today, what am I going to sell tomorrow?" I got back on the train heading home, and I thought to myself, I'm in the wrong business. This is patient care. It's not business.

I had a couple of friends who had made that transition from biomedical engineering to medicine. I applied, and within a couple of weeks I was accepted to stay right at Penn for medical school.

Dr. de la Cruz-Muñoz: So this engineering background is probably what led you into innovation and all the new things in surgery.

Dr. Estape: There's no question. Some of us who do this, and I'm sure you're the same, we're techies. We all get the newest iPhone. I have the Tesla. We're always moving to get more technology. I've always been a gamer, always played video games, always been into technology. Sure enough, that's what led me to the pathway where we are now.

Sit Down With Your Patients

Dr. de la Cruz-Muñoz: That's pretty cool. You already told me who shaped your early career. What did she teach you that you still do every day?

Dr. Estape: Spend time with patients. One of her things was that when you go in to see a patient, you sit down. Still to this day, I pull up a chair. The first time I meet a patient and do a consult, we sit down and have a conversation. It's not just standing at the bedside saying, "Let me examine your belly," and moving on. You sit down and talk with them, and it's not just about medicine. You ask them about other things as well. You have to make that connection first, and once you do, you can start getting into the medical portion of it. It's not a 30-minute discussion like she would do, but it's a 5- or 10-minute discussion to have a good connection with them, and then move on to why we're there.

Dr. de la Cruz-Muñoz: A lot of that's lost now in medicine, I think. I train residents, and I tell them this all the time. Sometimes the emergency room doctor sees the patient, and that initial history is just copied and pasted, copied and pasted, copied and pasted. Nobody sits down and redoes it. So I tell them: if I see that you copied and pasted the HPI, the history of present illness, and it's not something unique that you did, I know you didn't see the patient, and I'm going to have to go see the patient and get the real information. I always see them anyway, but never believe what other people tell you.

Dr. Estape: That's funny. I've told the administration they need to eliminate the cut and paste from one doctor's note to another, because I see the exact same thing you're talking about.

The Hardest Period of His Career

Dr. de la Cruz-Muñoz: Tell me about the hardest period in your career. What did that show you?

Dr. Estape: What a great question. After I left the university, where I was for seven years, I came out into private practice and helped the Baptist Health system build their cancer center. I was the founder of their robotic program, helped build the cancer center, and was the first director of the gyn oncology division. Then they brought in a new physician services executive. I won't mention his name. He sat down with me, and at that time I had a massive practice. We were building everything, and I had brought in three other partners. He called me a "plug-and-play physician." I said, "I don't even know what a plug-and-play physician is." Essentially, what he said is that this is about the system, not the doctor. He could take me out, put somebody else in my position, and they would do just as well. I said, "Really? You don't quite understand the way medicine works."

That was the point at which I decided to leave Baptist, but I told him a little story before I left. I have a good friend who runs the 3M conference, which is the Mayo, MD Anderson and Memorial Sloan Kettering conference, and I lecture there every year. He wanted me to give a lecture on why I'm so busy, and he prefaced it with a question. He's from MD Anderson in Houston. He asked, "What percentage of the cancers in the Houston area do you think MD Anderson captures?" I said, "90%. If I live in Houston and I get cancer, I'm driving myself, walking, taking the train to MD Anderson." He said, "1%."

That was one of those eye-opening things. I started reviewing it and figuring out why, and it was doctor-to-doctor referral. If I have a patient who needs your type of surgery, I'm calling you. I say, "Nestor, I've got this patient who needs your services." I'm not going to send them somewhere they have to go through three phone systems and end up seeing the most junior person, who might have 80% protected time in the lab and does three cases a week. I know what they're getting when I send them to you. They had everybody sitting in the ivory tower and nobody out in the community meeting other doctors for referrals. They've changed that since then.

That was probably the most difficult time in my career, because things were going great. We had good contracts and a great practice. I had a real falling out with Baptist and decided to go out on my own for a few years. Then HCA recruited me to come over and help build their program, and it's been great. There are always changes in our careers in medicine, and everything always works out for the best. God's always taking care of me and my family, and surely He'll continue to do that.

Engineering, Robotics and Medical Innovation

Dr. de la Cruz-Muñoz: You told me about when you decided to quit engineering. Have you ever thought about quitting medicine?

Dr. Estape: No, I love what I do, and I love doing both. I still spend a lot of time with robotics companies. I sit on the advisory board for five or six companies. On Wednesday morning I'm flying to Lincoln, Nebraska, to do some work with Virtual Incision. They have the small robot. The same person who helped develop the Mars rovers developed the MIRA robot. I helped them do their FDA trials for gyn, which were just approved, and now they have an even smaller robot. The robot itself fits on top of the patient.

So I still get to work with companies like Johnson & Johnson, Intuitive, Virtual Incision and Activ Surgical, where I can still get my fix of engineering and guide these young engineers. Engineers have incredible ideas, but a lot of times they don't translate to medicine. I feel like I'm in the right spot to tell them, "That's an incredible idea, but this is what we need, and this is how you need to tone it down to get it to do this." I've done enough engineering and enough medicine that I can guide these companies and young engineers in the right direction to help medicine.

Dr. de la Cruz-Muñoz: I always felt that I was a frustrated engineer. I didn't know about engineering when I went to school, but I would have loved to do that. And just so the audience knows, if there's one gyn oncologist in the world who is the technical guy, the robotics guy that the companies go to, it's definitely Dr. Estape. You've helped develop a number of different robotic systems.

What Separates a Good Surgeon From a Great Surgeon

Dr. de la Cruz-Muñoz: You've built a reputation for excellence. The medical community knows it and the patients know it. What do you think separates a good surgeon from a great surgeon?

Dr. Estape: To me, it's twofold. The first is the personal aspect. I make sure that I train all the doctors around me. I don't try to keep my knowledge to myself. If somebody wants to learn, come on, I'll teach you. You're not taking my business. There's not enough time in my life to do all the surgeries that need to be done, not even in my own little space here.

You have to leave a legacy. People say you can't take your money to your grave. Taking this knowledge to the grave is not a good idea either, because at some point somebody in my family is going to need it. Somebody in your family is going to need it. I'm going to need it. Every one of us is a conglomeration of all the people who have trained us, so we have to keep training people. If you need help with your case, I'll come and help you. Helping surgeons get through their learning curves and push the envelope has been a great thing. Some of the business people ask me, "Why do you do that? You're giving away your business." I tell them it actually increases my business, because now those surgeons can do a lot more, they know what they can't do, and they pass me the tougher cases.

Second, one of the things a lot of surgeons don't understand is that you have to be an anatomist. You have to know your anatomy. Every slow surgeon I see is not comfortable in the retroperitoneum. They're not comfortable knowing where this artery or that vein is. You have to spend time in the lab. There are certain things your partners, mentors and professors can teach you, but you have to do a lot of it on your own. You don't become a great surgeon working nine to five. You have to go to meetings on your own. I don't just go to the gyn sections. I go to the urology sections, the neurology sections, and other sections to learn what's out there. Truthfully, I think if you're a great anatomist, you'll be a great surgeon.

Dr. de la Cruz-Muñoz: It's true. I know general surgeons you helped train early in their careers who feel a lot more comfortable operating in the pelvis because they worked with you and watched you operate. When I was asking around, they were very thankful for everything you did for them.

What Patients Misunderstand About High-Volume Surgeons

Dr. de la Cruz-Muñoz: What do you think patients misunderstand the most about what you do?

Dr. Estape: My wife does these little Instagram posts called Women's Health on Wheels. One of them got over 7 million views. It was a day when I had done 14 surgeries, and you see me coming in and out of surgery multiple times. As a joke, I put my head sideways like I'm tired. We're very efficient. We work out of three rooms. A lot of the comments said, "I'm not going to see that doctor. He's too tired. There's no way he's doing a good job."

What they don't realize is that every study done in medicine now says you want to see the doctor with the highest volume and the best efficiency. If you're going to a doctor who only does two cases a day, but each one takes four hours, when it can be done in 20 minutes, that's probably not the doctor you want. Every trial has shown the same thing: you want to go to a center that knows what it's doing. And it's not just me. It's my team around me: my surgical assistant, my tech, my nurse. They get me the things I need right away. They're ready for the surgery.

I'll give you another example. There was a lawsuit I was involved in where I came in to repair an injury that is a known complication of that particular surgery. The attorney tried to make a big deal of it: "How do you know what you were doing? You did 12 cases that day." I used it to my advantage. I said, "Great. That's the doctor you want helping you." Whether it's attorneys or patients, they don't quite understand that you want the high-volume surgeon. That's the person who's going to do the best for you in surgery, because they know what they're doing.

Dr. de la Cruz-Muñoz: I hear people say, "You don't want somebody rushing through." They don't understand. It's not rushing. It's efficiency that develops over time with practice and repetition.

Dr. Estape: When we were switching from laparoscopy to robotics, I used to run a conference where we did two live cases side by side: the same procedure done laparoscopically and then robotically. Even novices who don't do a lot of surgery could see I wasn't rushing through the case. It was very efficient. Every movement meant something. Every slide of my scissors meant something. I didn't lose any blood. I was more radical in the cancer procedure, without wasting any time, because I know my anatomy. People started to realize that efficiency and knowledge of anatomy are what get you through a fast surgery.

Dr. de la Cruz-Muñoz: That's true. I've watched you operate, and I'm petrified because I don't know the pelvis very well. That's not where I operate. I see you flying through it, everything is clean, and at the end everything is perfectly dissected away. It's experience and repetition.

Why the Future of Cancer Care Looks Bright

Dr. de la Cruz-Muñoz: You've been a leader in women's health for years. Is there anything that makes you optimistic for the future?

Dr. Estape: Absolutely. Let's get away from robotics for a second. We've done a huge amount of work in robotics and minimally invasive surgery, and it's not just the cosmetic part. I can see deeper and do so much more robotically than I can laparoscopically or open. But to me, one of the biggest advances has been in the oncology side of treating these patients.

With the human genome project, we can now find defects in genes and proteins, and drug companies are working on molecular profiling of tumors. You don't just have ovarian cancer anymore. You have HRD-deficient, BRCA-positive cancer with a high tumor mutational burden. Based on all these factors, we can say your prognosis is this or that. If you have a BRCA mutation, I can use a PARP inhibitor. If you have PD-L1, I can use another drug called Keytruda. Tumors are becoming more and more specific, and we know which drugs to use. It's not picking a drug out of a hat and hoping it works.

When I first started, the five-year survival for ovarian cancer was probably 30%. We've been able to push that out to almost 60 to 70%, and some are cured. We're starting to talk about maintenance therapy, where we keep patients on something to keep the cancer from coming back without a lot of toxicity. And we're at the infancy of molecular profiling. We have maybe 15 drugs we can use this way right now. Imagine where we're going to be five years from now. You'll be able to take out a tumor and, based on its molecular profile, know which drug to use, stay on it, and keep the tumor controlled.

I probably spend more time reading about that than anything else, because new drugs and new protocols come out by the day and by the week. The NCCN guidelines change almost weekly now. It's been super exciting over the last five or six years to see how we've changed the treatment of all cancers, and surely in gyn oncology.

Why a Gyn Oncologist Gives His Own Chemotherapy

Dr. de la Cruz-Muñoz: In gyn oncology, do you give the chemotherapy yourself, or do patients go to a medical oncologist?

Dr. Estape: I do the chemotherapy myself. Some gyn oncologists send it to a medical oncologist, but this is what we were trained to do, and I love to do it. I have an infusion center at Kendall and an infusion center at Mercy. At Mercy I also have a radiation center, so when patients need the combination of radiation and chemo, it can be done in the same place.

It's becoming a dying art in gyn oncology. We're all trained to do chemotherapy, and some choose not to. I love it, because then the surgeon is involved through the entire process, not just one short part of it. People ask me, "Why do you want to do that? Just send it to a medical oncologist." I love the medical oncologists, and some of them are really bright, but they have to keep up with the literature for brain, lung, pancreatic, liver, colon and breast cancer, plus ovarian, cervical and uterine cancer. That's hard to do. I only have to keep up with my cancers, and because that's all I see every day, I think I do a better job with them.

Endometriosis: The Disease Nobody Is Researching

Dr. de la Cruz-Muñoz: That's a surprise for me. What topic in women's health is not talked about enough?

Dr. Estape: There are a couple that really haven't been researched or talked about enough. One is endometriosis. Endometriosis is a real issue that causes severe pain and infertility for women. I've brought in a couple of partners, one here in Miami and Dr. Miguel Luna in Palm Beach, who is a world expert in endometriosis. I brought him down from the Cleveland Clinic. Endometriosis is a lifelong problem, and there's almost no research being done on it. We can molecularly profile a tumor, but we've done no work on molecular profiling of endometriosis or figuring out how to treat it.

When I lecture medical students, I tell them the old treatment paradigm had three parts. One is making you less of a woman: birth control pills to decrease your hormones, which only temporizes it for a short time. Another is making you an old woman: medicines that turn off your ovaries completely. That treats the endometriosis, but now you have all the symptoms of menopause, the hot flashes and dryness. The third is turning you into a man, because one of the things they used was high doses of testosterone. That takes away a lot of your female symptoms, but now you have to start shaving. That was the extent of it.

There may be one lab at UCSF doing work on endometriosis, but there's not a lot of money, time and research spent on it. It's a huge problem we see weekly, even daily, and we haven't made big improvements over the last few years.

Dr. de la Cruz-Muñoz: At the SRS meeting there were a lot of lectures on the surgical side: taking out colons, doing disc resections, removing the entire peritoneum. You'd think you could manage it medically without all these radical resections and multiple recurrences.

Dr. Estape: The surgeons think the resections are exciting, but the patients sure don't want them. Then a year or two down the road, you're dealing with the same thing. Even bigger for these young women is the infertility that endometriosis brings on. There's a lot of work to do.

Redesigning the Patient Experience for Women

Dr. de la Cruz-Muñoz: If you could redesign the patient experience for women, what would you do? I have a feeling you already did it in your clinic, but how would you teach other gynecologists or primary care doctors to change it?

Dr. Estape: That's a great question, Nestor. Unfortunately, we've had to go the opposite way. If I wanted the perfect experience, I'd see 12 to 15 patients a day in the office and spend more time talking with them. But we are so understaffed with gyn oncologists and surgical gynecologists in this country, and surely in South Florida, that I've had to change my practice. Instead of spending more time with each patient, we have to triage so I can get more of the patients who need surgery into surgery.

Most obstetricians are so busy with obstetrics that they don't have time to go do a four-hour case, so they send us everything: D&Cs, endometriosis, ovarian cysts, fibroids. I have nurse practitioners and PAs in the office who see the mostly benign patients and set them up for surgery. A lot of times I don't meet those patients until the day of surgery, because otherwise they'd have to wait six, eight, ten months. If it's a cancer patient, I'll see them in the office. Mondays are when I spend more time with my cancer patients, because they need it.

Is it ideal? No. But I don't want cancer patients waiting like they do in Canada. In Palm Beach I see a lot of Canadian patients who were diagnosed in January and scheduled for surgery in June or July. They come down in the winter months and we do their surgeries right away, including the wife of one of their prime ministers. This is where allied health professionals really come into play. In Miami we have a lot of clinics, like Leon or ChenMed, where non-surgical gynecologists or allied health professionals triage the patient and send them to me. For some of these patients, I'm essentially just a technician: I do their surgery and get them back to their doctor. Those we can triage quickly, and with the cancer patients I spend more time. We are definitely not staffed to take care of every patient the same way.

What Other Specialties Should Know About Gynecologic Oncologists

Dr. de la Cruz-Muñoz: What do you wish other specialties understood better about gynecologic oncologists?

Dr. Estape: As you said earlier, if you need somebody's help in the pelvis, that's what we do. I live in the retroperitoneum of the pelvis. I live in the obturator space, around the obturator nerve, in the deep portions of the sacrum, in the pararectal and paravesical spaces. I'll call you when I'm working near the biliary tract or the small or large bowel. But a lot of times the colorectal surgeon has difficulty getting the ureters out of the way. I spend a lot of time with the colorectal surgeons, and I tell them, "You don't need to put in lighted stents. You don't need a urologist to come in. I'll dig them out for you in two seconds, and I'll show you how to do it." I also spend a lot of time fixing ureters that get injured in other surgeries.

These are things you need to learn to do in the pelvis. If the colorectal surgeon who trained you didn't know how to do it, you're not going to be able to do it on your own. I learn a lot when I go to the colorectal and urology meetings. We all need to partner up more and show each other where we're experts.

Obesity, Endometrial Cancer and Bariatric Surgery

Dr. de la Cruz-Muñoz: In your field, where do you see the biggest opportunity to collaborate with metabolic and bariatric surgery, between you and me?

Dr. Estape: The perfect patients are endometrial cancer patients. Obesity is the number one cause of endometrial cancer. As women go into menopause, fat cells have an enzyme called aromatase. That enzyme converts androstenedione to estrone, which is a weak estrogen. After menopause, they're not ovulating anymore, so they don't have progesterone. Not only are they still producing some estrogen from the ovaries, but they also have estrone from that peripheral conversion. The number one risk factor for endometrial cancer is obesity, and I would tell you 95% of these endometrial cancer patients are obese. You don't see that in cervical cancer, and you really don't see it in ovarian cancer. You see it in endometrial cancer.

There really hasn't been any data on treating endometrial cancer patients after surgery with bariatric, or metabolic, surgery in addition to the way we treat them now, to decrease their risk of recurrence. The vast majority of these cancers are estrogen receptor positive. We used to put them on Megace and other hormonal medicines. I think they would do better from a lifestyle standpoint, and in their ability to function, if they went through metabolic surgery after or during the time they have their endometrial cancer. I saw what you were doing the other day. You did your procedure in no time. Doing something like that for these patients would be ideal.

Dr. de la Cruz-Muñoz: The incredible part with these patients is that weight loss would help their recurrence rates, their mortality, everything. But Megace…

Dr. Estape: Yes, it's a different dose, but it still does it. The dose used to make patients hungrier is 800 milligrams a day. We usually give them 80 milligrams a day, but even at 80 milligrams it still has that effect, not to the same degree. So you're right. It's the opposite of what you want to be doing for them. With surgery, you're not only treating their endometrial cancer, you're helping them treat their lifestyle as well.

Symptoms Women Should Never Ignore

Dr. de la Cruz-Muñoz: My wife said, "You have to ask him the questions patients need to know." So I have a few questions that patients would love to hear answered straight from the experts. What symptoms should a woman never ignore?

Dr. Estape: Bleeding. Abnormal bleeding. A lot of the cancers, and a lot of the benign conditions, start with abnormal bleeding. One of the issues with women is that they're the ones who take care of the household. The children come first, the husband comes first, the household comes first, their mother comes first, everybody else comes first, and they're last. So when they start having abnormal bleeding, whether it's bleeding between periods, bleeding during menopause or bleeding after menopause, they sometimes put it off way too long. It may be nothing, but if you find these cancers early, you can treat them very easily. When we find endometrial cancer early, we can cure it 99% of the time.

Another one is vulvar itching or vulvar burning. I can't tell you how many vulvar cancers I see that, instead of being one little millimeter, are huge tumors. Why? Because the patient waited too long to come in, or treated it with a cream, or went to Dr. Google and did what Dr. Google said. After six months it's a big tumor, and you'd be surprised how big some of these tumors can get. If you have something abnormal, don't be ashamed of it. Come see your doctor.

Incontinence is another issue a lot of women have after having children, and they feel ashamed of it. You cough or sneeze and you lose urine. Don't be ashamed. There's a simple procedure that can fix it. And you don't always have to be the full-time caregiver of the whole family. Take care of yourself so you can take care of your family better. Hospitals have realized that the family goes where the woman goes. Wherever the mother takes care of herself, that's where she takes her kids, her husband, her mother and her mother-in-law. When you take care of the caregiver and help her take care of herself, things go a whole lot better for her and for everybody around her.

Dr. de la Cruz-Muñoz: I think women are more likely to blow off abnormal bleeding because they're used to bleeding every month, so if it happens at a different time, it just seems a little weird. If it happened to me as a man, I'd be in the emergency room the first day, freaking out.

Screening Tests That Actually Matter

Dr. de la Cruz-Muñoz: What screening tests actually matter for women's cancers?

Dr. Estape: Prevention. The Pap smear, for sure. We've just about cured cervical cancer by getting Pap smears done. You should have it done yearly, or at minimum every two years, and Pap smears have to be done well into menopause. Mammograms, too. A lot of times I hear, "I didn't get it done because nobody in my family has cancer." Truly, only one in ten women with breast cancer has a family history of breast cancer. There isn't great screening for ovarian cancer, but only one in seven women with ovarian cancer has a family history of ovarian cancer. Almost nobody with cervical cancer has a family history. So don't think your family history protects you from cancer. Pap smears for sure, mammograms for sure. If you're at high risk for certain cancers, there's CA-125 and ultrasound for ovarian cancer, but those are not great tests.

The Real Risk Factors for Gynecologic Cancers

Dr. de la Cruz-Muñoz: What are the real risk factors for gyn cancers? You talked about obesity for endometrial cancer. Do any others really stand out?

Dr. Estape: Let's take cervical cancer. One of the risk factors is infection with human papillomavirus. A lot of people think HPV is only a sexually transmitted disease, and it is not. HPV is a skin contaminant. We expect anywhere from 80 to 90% of people are infected with at least one of the hundred subtypes of HPV. So a lot of times people say, "I'm not going to get cervical cancer, so I don't need a Pap smear, because I'm not sexually promiscuous." You don't have to be. The trial for the Gardasil HPV vaccine started at 9 years of age, and at 9 years old, 40% of boys and girls already had antibodies to HPV. You can't tell me that 40% of 9-year-olds are sexually active. It just doesn't happen. HPV is a very common risk factor that we all have, and that's why everyone should get a Pap smear.

Family history, surely, though again that's the smaller group of patients. If you have a family history of endometrial cancer, colon cancer, ovarian cancer or any type of cancer, see your doctor. With some of the big syndromes, like Lynch syndrome, somebody comes in and says, "My dad had colon cancer, my uncle had colon cancer." That also puts you at risk for endometrial cancer. Make sure all these things are tested and your gynecologist is aware of your family history.

Myths About Women's Cancer

Dr. de la Cruz-Muñoz: Are there any myths about women's cancer that patients should stop believing?

Dr. Estape: Good question. One that I hear commonly is that if you cut the cancer out, you're going to make it spread. It's not true. Our job as surgeons is to get the tumor out without breaking it or cutting through it, with good margins around it. When we can't, it means it has already spread outside the area where it started, whether that's the cervix, the uterus or the ovary. Ideally we don't want to cut through tumor. If the tumor is too widespread, we'll treat it with chemotherapy or radiation first and not start with surgery. But having surgery doesn't increase the risk of recurrence. For most cancers, if you can have the surgery done, it improves your short-term and long-term survival.

PCOS, Now PMOS, and Cancer Risk

Dr. de la Cruz-Muñoz: Polycystic ovary syndrome, PCOS, is now called PMOS. It's very common in women. Does it increase the risk of any gyn cancers?

Dr. Estape: It does. Before PCOS it was Stein-Leventhal syndrome. It's had a million names, and it's another one of these conditions that hasn't been studied very well, because we still don't know how to diagnose it for sure. Essentially, it means you don't ovulate, and it also leads to metabolic syndrome, which leads to obesity. The biggest issue is that you don't ovulate normally, so you have continuous estrogen. That continuous estrogen can lead to endometrial polyps, endometrial precancers and endometrial cancer. One of the few times we see endometrial cancer in young women is in young women with PMOS.

If you fit the criteria, meaning a young woman who hasn't been able to get pregnant, who's obese, who may have hirsutism (a little more hair growth on the body and face), whose periods are irregular or random, and who has abnormal bleeding, you have to see your gynecologist. That gynecologist had better understand that they need to do an endometrial biopsy. The rule is that above age 35, you should have a biopsy if you're having abnormal bleeding. But if you fit the criteria for PMOS, you need a biopsy even before age 35, because those are the young women who develop these cancers.

Hormone Replacement Therapy

Dr. de la Cruz-Muñoz: Another one my wife definitely wanted to know about is hormone replacement therapy in perimenopause. It seems like we're hearing more about it now, along with peptides and supplements. Any concerns from you as a gynecologist?

Dr. Estape: That's a great question. Twenty-five or thirty years ago, I participated in the Women's Health Initiative trial and the HERS trial. Those were the two trials that led to all these problems with hormones. Wyeth-Ayerst sponsored a study that started women up to age 65 on hormone replacement therapy. That trial showed incredible benefits, but it also had a slightly higher risk of heart attacks at the beginning of the trial.

Women live longer than men in part because of estrogen. Estrogen keeps the arteries clean and keeps plaques from building up; it works through enzymes called matrix metalloproteinases. When you start estrogen again well after menopause, it starts to break up those plaques, and you can have a slightly higher risk of heart attack. Not because estrogen causes the heart attack, but because it's trying to clean the blood vessel. Everybody took this as, "Oh my God, you have a higher chance of dying of heart disease if you take estrogen."

The women on estrogen plus progesterone also had a slightly higher risk of breast cancer, but it was about one more case per 10,000 women. The risk was low. And the studies didn't look at the benefits, which far outweighed the risks: less colon cancer, less osteoporosis and osteopenia (bone thinning), and all the other things estrogen does. It got a black-box label, and everybody moved away from it, including gynecologists who didn't understand the study. Because I was one of the gynecologists on the study, I went around for a long time trying to teach people what it really said, and nobody was listening.

Hormone replacement therapy has a place, and a lot of women feel a whole lot better on it. It protects their skin, bones, heart and brain. There's been some work on cognitive function as well. That data isn't as strong, but almost all women will tell you they feel better, think better and remember better on hormones. See a gynecologist, and not just any OB/GYN. See a gynecologist who mostly does gynecology and sees women in menopause. If you go to an OB/GYN practice seeing 52 pregnant women a day, they don't have time to talk with you about hormone replacement, dryness, hot flashes, your chances of osteoporosis and everything else that happens in menopause. They'll give you 10 minutes. As you get into menopause, reach out to a gynecologist who focuses on menopausal and perimenopausal health.

A Patient Story That Stays With Him

Dr. de la Cruz-Muñoz: Is there a patient story that sticks with you, one you think about often?

Dr. Estape: There is one. A young woman I still see to this day, who is an X-ray technician for a local hospital system. I won't mention which one, and you'll understand why in a second. She started getting shoulder pain. She went to the emergency room, they did an X-ray and found nothing, and they sent her to an orthopedic surgeon, who did all sorts of workup and found nothing. A month later, the shoulder pain kept getting worse, and she was having some chest pain too. Another workup; everything seemed fine. Then she started having abnormal bleeding and came to see me.

I looked at the X-rays, and there were bone metastases. This wasn't an orthopedic issue. The radiologist had missed them every time. She had an endometrial stromal sarcoma of the uterus, with a big uterus, and she had never had children. I told her what we needed to do, and we did her surgery. Then, rightfully so, she went to a big center for a second opinion, I believe MD Anderson or Duke. The gyn oncologist there told her, "Go home, make sure your will is in place, take care of yourself, because you're not going to survive this."

So I sat down with her and said, "Look, these are the drugs we have available for this, and for the lesions in your bones, radiation works very well." We treated the bone lesions with radiation, gave her chemotherapy and followed her closely. She's now about 15 years out, alive, with no evidence of recurrent disease. Her cancer was missed at first, and then she was told to go home and die.

Every time I treat a patient whom some academic center has told, "Just go home to die, there's nothing that will help you," I remember that there's always something you can try. Granted, I still lose a lot of patients, because of the volume I have and the bad cancers that won't respond to anything. But you have to try. Look at the studies. Maybe two doctors in London did a trial of three particular drugs for endometrial stromal sarcoma and had success. Look it up. Spend your time researching for your patient. Not everything is black and white; there's a lot of gray in this world. Those are the patients I'll sit with on a Saturday morning or at the end of a clinic day. You see my sticky notes everywhere. I'll spend a little extra time figuring out what I can do for you, so that at least we give you a chance.

How He Copes When Patients Don't Survive

Dr. de la Cruz-Muñoz: Part of the reason I do what I do is that I have a difficult time dealing with patients not doing well and passing away. Luckily, in metabolic surgery that's pretty rare, but I'm sure in oncology it happens a lot more often. How does that affect you?

Dr. Estape: I work harder. There's probably more I could have done. In the beginning, my wife thought it was very morbid that I kept pictures of all the patients who passed away. That was my motivation for working harder, doing more research and figuring out how to do more radical procedures for these patients.

I'll give you one good example. With ovarian cancer, you used to open a patient from top to bottom to do the surgery, and if the cancer came back, you'd open them up again. Who wants a major abdominal operation three, four or five times? Now, with minimally invasive surgery, I can go in seven or eight times, not have to deal with adhesions, and keep removing their localized disease. Things like that have pushed those of us who do this to keep figuring out how to provide care for these patients. It affects the heck out of me, but it also makes me want to work harder. We can do more for these patients.

Life Outside Medicine

Dr. de la Cruz-Muñoz: What do you do outside of medicine that keeps you grounded?

Dr. Estape: I have two granddaughters now whom I get to see in Orlando all the time. I changed my schedule so that on Fridays I'm at my office in Palm Beach, and a couple of times a month, as soon as I finish, we drive up to Orlando and spend the weekend there. I love to play golf, although in this summer heat I'm not getting out very often. Barb and I like fixing up homes. We're in the middle of renovating ours, and it's something we do well together. And I've gotten the travel bug. I like to travel, see new places, meet new people and see what's going on in this great world of ours.

Dr. de la Cruz-Muñoz: Your wife is in medicine as well. Is your household discussing medicine all the time, or do you try to get away from it?

Dr. Estape: We rarely discuss medicine at home. She's a nurse, and she's been running my robotic program for more than 20 years. That's her desk right there; we've set up to work together. When we're working together, it's all business, but outside of work we have many other interests we love doing together. We rarely talk medicine unless one of us is on the phone with somebody.

Advice for Residents

Dr. de la Cruz-Muñoz: You work with residents now. What's the biggest thing you try to get them to understand while you have your time with them?

Dr. Estape: That the patient comes first. They're not here to cut and paste, like we were talking about earlier. They're not here to just repeat what the radiologist said. They're here to practice medicine. If the first doctor made an error in the diagnosis, you're just propagating that same error. You have to do your own work, form your own ideas and figure out what's going on with this patient.

And you have to put in your own time. When I first started, I created the gyn laparoscopy program at the University of Miami, because nobody was doing it at the time. We would spend every Saturday at the zoo doing animal labs, practicing laparoscopy so we could bring it to patients. Then we'd tell our attendings, "Let us do this ectopic laparoscopically. Let us do this cyst." We went out of our way. Don't settle for what's here. Push the envelope and keep learning and doing more, because medicine is going to change. If I hadn't changed, I would never have started laparoscopy or robotics, and we would never have gotten to where we are now.

A lot of residents think the way they train is the way they'll practice for the rest of their career. If that's how they think, everybody is going to pass them by. You have to keep evolving, and now it's on you. It's not on your attending or your program anymore. Those first years of residency are there to ground you in basic knowledge. If you want to be a nine-to-five worker, go ahead. If you want to advance medicine, do the right thing for your patients and become a great doctor and a great surgeon, it's on you. You have to put in your own time like everybody else.

Dr. de la Cruz-Muñoz: It's funny. When I see patients in clinic with a difficult problem who have seen a bunch of different doctors, they always start with, "I've been told I have this and this." I tell them, "Don't tell me what anybody else told you. Tell me what you feel. Let's start with that."

What's Next: Bringing Care to Rural Florida

Dr. de la Cruz-Muñoz: What's the next chapter for you?

Dr. Estape: People ask me when I'm going to retire, and I have no intention of retiring at this point. I just turned 62 last week, and I love what I do. As long as I can do it, I'll keep doing it. I've been able to bring in some people and train the residents as well. Hopefully I'll travel a little more than I have in the past, but still come home and do what I love. I've also done a lot of work on advisory boards for companies, helping advance the technology and pushing the engineers and companies in the right direction.

Dr. de la Cruz-Muñoz: The question wasn't leaning toward retirement, because I don't envision that at all. You've grown and evolved over time. You were at Baptist with their program, now you're at HCA, and it has grown into a multi-county program. You're working with many different companies. I wondered if you had other plans for expansion.

Dr. Estape: For sure. There are still some hospitals in the Broward area where HCA has no complex gyn oncology care. Now that we've established Palm Beach, that's the next goal, and we're already recruiting.

But one thing I've noticed, especially at Palms West Hospital, the farthest west hospital in Palm Beach County, is that we see a lot of patients from rural Florida: Belle Glade, LaBelle, Clewiston. There is zero care for these patients out there. They get to a hospital, get transferred to a slightly larger hospital, and then get transferred to us. And they're only an hour or an hour and a half away. It's not like some states, where you're six hours from an urgent care center. Hopefully, with HCA being as big as it is, we can create some kind of outreach: an outpatient clinic, an RV, something to take care of these patients where they live.

The biggest issue I have every day is this: I see a patient in Palm Beach with ovarian cancer, and I have to treat her with chemotherapy. How do I get it to her in Clewiston? How does she drive back every week for her labs? Radiation patients have to come every day. At the SRS meeting, you were part of the telesurgery session. We've been working a lot on telesurgery, being in one place and helping doctors or doing surgeries somewhere else. Some of the surgeries done so far have been in rural parts of China and in Uganda. But you don't have to go that far. Look at rural America. How many parts of the U.S. have zero access to minimally invasive surgery, or any surgery, chemotherapy or radiation? We can start right here, figuring out how to take care of patients in central Florida who have no daily access to the advanced things we do a stone's throw away from them.

Dr. de la Cruz-Muñoz: It is incredible how isolated people can be when they're so close.

His Legacy

Dr. de la Cruz-Muñoz: What part of your work do you hope outlives you?

Dr. Estape: I hope the training I've done, for the residents and the fellows I've trained, and some of the technologies we've been able to advance, will continue on, and that people still get that fire to keep learning and keep doing more and more.

Dr. de la Cruz-Muñoz: Ricardo, thank you very much. This was incredible. I appreciate your time, and I'm sure people are going to learn a lot from this episode. Thank you for all that you do.

Dr. Estape: Thank you so much, Nestor. It was awesome.