Unmuted: Equity in Focus - Rethinking Vulvar Cancer Treatment: The STRIVE Study

Unmuted: Equity in Focus is back with an episode spotlighting the future of personalized care in vulvar cancer. 🎙️💙 

Sabrina is joined by Dr. Amy Jamieson, Gynecologic Oncologist at Vancouver General Hospital and BC Cancer, to talk about the STRIVE trial — a newly launched study exploring whether HPV and TP53 status can guide more tailored, less invasive surgical approaches for vulvar squamous cell carcinoma. 

Dr. Jamieson walks us through why vulvar cancer has been historically understudied, the critical difference between HPV-associated and HPV-independent disease, and why moving beyond a “one-size-fits-all” surgical model could transform outcomes and quality of life for patients. She also discusses the importance of integrating patient-reported outcomes, such as sexual health and fear of recurrence, and what it will take to translate molecular stratification into real-world practice. 

Tune in for a clear, accessible conversation about why STRIVE matters — and how this trial could shape the next chapter of vulvar cancer care.  

Resources:

https://ascopubs.org/doi/10.1200/JCO.2025.43.16_suppl.TPS5637  

For more information on the Gynecologic Cancer Initiative, please visit https://gynecancerinitiative.ca/ or email us at info@gynecancerinitiative.ca

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Transcript

00:00:02 Intro 

Thanks for listening to the GOSH Podcast, the Gynecologic Oncology Sharing Hub. We share real, evidence-based discussions on gynecologic cancers featuring stories from patients, survivors, researchers, and clinicians. Our podcast is produced and recorded on traditional unceded territories of the Musqueam, Squamish, and Tsleil-Waututh Nations. It is produced by the Gynecologic Cancer Initiative, a BC-wide effort to advance research and care for gynecologic cancers. 

00:00:35 Sabrina 

Hello, and welcome back to another episode in our Unmuted: Equity in Focus series on the GOSH Podcast where we highlight stories, expertise, and community perspectives on equitable gynecologic cancer care. Today we are joined by Dr. Amy Jamieson, who is an Assistant Professor at the University of British Columbia and a Gynecologic Oncologist at Vancouver General Hospital and BC Cancer. Dr. Jamieson completed her obstetrics and gynecology residency at the University of Otago in New Zealand and her gynecologic oncology fellowship at the University of Sydney and UBC. She was the first recipient of the Miller-Mindell Translational Research Fellowship with UBC/GCI. Her research is focused on molecular stratification of endometrial and vulvar cancers. Dr. Jamieson is here to talk about the findings from the STRIVE trial, or STRatIfication of Vulvar Squamous Cell Carcinoma by HPV and p53 Status to Guide Excision, done in collaboration with Dr. Jessica Mcalpine. Welcome to the podcast, Dr. Jamieson. 

00:01:51 Amy 

Yeah, thanks for having me. 

00:01:53 Sabrina 

Excited to have you here. I was thinking we could start because vulvar cancer is a disease that's been understudied and under discussed in gynecologic oncology. So I was wondering if you wouldn't mind sharing with the listeners a bit about what led you to focus your research on vulvar cancers? 

00:02:10 Amy 

Yeah, well, I would say it's, you know, my patients that have motivated me to focus on my research on vulvar cancer. So, you know, being a gynecologic oncologist, I look after patients who have endometrial cancer and vulvar cancers can be very aggressive and our treatments can be very morbid for patients, meaning, you know, associated with lots of side effects and can really affect patients' quality of life. And like you said, unfortunately, vulvar cancer has traditionally been understudied and underfunded in research and has not received much public attention. And, you know, this is very frustrating as we cannot improve care for our vulvar cancer patients without research, research is how we advance care in medicine. So yeah, this is what really motivated me to do research in this area. 

00:03:03 Sabrina 

Okay, and from my understanding, there's actually two main types of vulvar squamous cell carcinoma. There's HPV-associated and HPV-independent. For our listeners who might not know, would you mind explaining the difference and also why distinguishing the two matters for treatment for these cancers? 

00:03:21 Amy 

Yeah, absolutely. So yeah, so first I might just start off by saying vulvar squamous cell carcinoma is the most common type of vulvar cancer. And you know, that's just what we're going to be speaking about, that specific type vulvar squamous cell carcinoma. And that accounts for about 90% of all vulvar cancers. And yeah, we now know that there are two main pathways to developing vulvous squamous cell carcinoma. And one pathway is related to infection with the human papillomavirus, which we call HPV for short, and that leads to HPV-associated vulvar squamous cell carcinoma. But the other pathway is not related to HPV infection, and this is often related to chronic vulvar skin conditions, such as a condition called lichen sclerosus. And this pathway causes what we call HPV-independent vulvar squamous cell carcinoma. And the reason why it's important to differentiate between these two types is because we know these two types of cancer are very different. So HPV-associated vulvar cancers, for example, these cancers tend to arise in younger patients. These are often less aggressive cancers, and these patients often have very good outcomes. And this is very different to patients who have HPV-independent vulvar cancers. These cancers tend to arise in older patients, and these are often aggressive cancers with a high risk of recurrence, so the cancer coming back. So knowing if a patient who has just been diagnosed with a vulvar squamous cell carcinoma, knowing whether they have HPV-associated or HPV-independent vulvar cancer is very important, and this distinction should be performed on every vulvar cancer patient now. And this isn't just a prevention recommendation, this is a global recommendation. 

00:05:15 Sabrina 

Okay, I think that was a great description of the different types of vulvar cancer for everyone who is new to the field. The STRIVE study was testing a new approach that personalizes surgery based on HPV and P53 status. How does that differ from the sort of one-size-fits-all approach to vulvar cancer treatment historically? 

00:05:37 Amy 

Yeah, so first I just want to start by saying that the STRIVE study is actually only recently opened, so it's not yet completed. So although it's been work in progress for many years, we are now open in several sites and recruiting across Canada. And we are also opening the study in several international sites as well. So it's only recently opened and started recruiting. You know, what the STRIVE study is about is that traditionally all vulvar cancer treatment guidelines have recommended that we treat all patients the same. So most of our vulvar cancer patients, if it's diagnosed early, are treated with primary surgery. And the surgery, what we do is we remove the vulvar tumor, aiming for at least an eight millimeter margin of healthy or normal tissue, both around and deep to the tumor. And then we also do surgery to assess the lymph nodes in the groin. And now what we have learned recently about these two different types of vulvar cancer, the evidence suggests that for patients who have HPV-associated vulvar cancer, remember these are often the less aggressive cancers, these patients are probably currently being over-treated with our surgical approach and these patients could probably have less extensive surgery. But for patients who have the HPV-independent vulvar cancers, and these are the more aggressive cancers, The evidence shows us that these patients are probably being undertreated with the current recommended surgery. So this is why we developed the STRIVE clinical trial, and as you mentioned, this stands for Stratification of vulvar Squamous Cell Carcinoma by HPV and P53 status to guide excision. And so what we're hoping that this study will show is that for patients who have the HPV-associated vulvar squamous cell carcinoma, these patients can safely have less extensive surgery, and hopefully this will improve quality of life for these patients and not impact their cancer recurrence. But for patients with the HPV independent vulvar squamous cell carcinoma. These are the patients who we think need more extensive surgery in order to lower the risk. So to prevent the cancer coming back. And so that is what we are studying in the STRIVE study. 

00:07:58 Sabrina 

Very interesting. You're mentioning or I've also been mentioning these molecular markers, HPV and P53. How do those influence reoccurrence risk and also treatment response generally, but also in the context of what you're studying? Yeah, so, you know, like I've already touched on, we've kind of learned in the past, you know, 5 to 10 years that HPV status is really important with our patients with vulvar squamous cell carcinoma. So again, the patients who have the HPV-associated vulvar squamous cell carcinoma, these are often, these cancers usually occur in young patients. And these tumors tend to be less aggressive, meaning the patients are less likely to go on to have a recurrence after surgery. And these patients typically have very good outcomes. And these patients often respond better to radiation treatment if this is needed as well, in addition to or instead of surgery. And this is quite the opposite to our HPV independent patients who most of these have a P53 mutation, hence why we use P53 as the other biomarker. And we know that these vulvar cancers tend to arise in older patients, and these tend to be quite aggressive cancers. These patients, unfortunately, have a high risk of the cancer coming back after surgery. And the evidence shows that these cancers are less likely to respond to radiation treatment if this is needed, you know, in addition to surgery or instead of surgery. So again, you know, these biomarkers and making this distinction is really important when we're considering treatment for our patients with vulvar cancer. 

00:09:45 Sabrina 

Okay, thank you for explaining that. And a unique part of your study, which I find particularly interesting, is that you're focusing on patient reported outcomes like quality of life and sexual health, and also fear of reoccurrence. Why was it important to include these perspectives alongside just your clinical outcomes? 

00:10:06 Amy 

Yeah, so I agree. I think this is an important aspect of the trial as well. And as I mentioned earlier, unfortunately, vulvar cancer surgery can be very morbid, meaning our patients can be left with both short and long-term side effects from the treatment they receive. These side effects can be very severe, and some will end up having a big impact on our patients' quality of life. So just some examples, you know, vulvar cancer surgery can be very disfiguring. It's quite often associated with, you know, after vulvar cancer surgery, patients often will have wound complications or, you know, delayed, prolonged wound healing in the area. Vulvar cancer patients following surgery can, you know, end up with difficulty passing urine and sexual dysfunction is very, very common after vulvar cancer surgery and pain and difficulty with pelvic exams is common. And the list really goes on about how many side effects patients can suffer after vulvar cancer surgery. So patient-reported outcomes are very important to consider when designing a clinical trial. Nowadays, we can't just look at the cancer outcome with our treatment. We really need to take into account how our treatments affect the patients because we know that Yeah, our treatments can be very morbid. And we have to take this into consideration when we're looking at changing a treatment. And that's why we built that into the trial. 

00:11:45 Sabrina 

Yeah, it's an incredibly important thing to include. So for patients who will hopefully be able to benefit from this research, what do you think that this more personalized approach will mean for them in practice in terms of recovery as well as their long-term well-being? 

00:12:01 Amy 

Yeah. So, you know, what we'll hopefully see with the study results is that, you know, we're hoping to show for our younger patients that have the HPV associated vulvar cancer, we're hoping to show that it's safe for these patients to have less extensive surgery. And, you know, because they're having less extensive surgery, hopefully some of those significant side effects that I just, you know, talked about, you know, will be, reduced for these patients and therefore, quality of life would be improved compared to the current treatment. So for example, things we would hope to see is perhaps less wound complications and healing problems, less post-operative pain and less sexual dysfunction, et cetera. So that's what we're really hoping to see in the patients who have HPV-associated vulvar squamous cell carcinoma. But the other group of patients in the study, so the patients with the more aggressive HPV-independent vulvar squamous cell carcinomas, we think these are the patients who need more extensive surgery to lower the risk of their cancer coming back. And if we can avoid a cancer recovery, recurrence in a patient, then we will avoid that patient having to undergo repeated vulvar surgeries, which a lot of these patients have to do. You know, when the cancer comes back, the patient has to have another surgery, which causes more, you know, scarring and can cause more problems. So again, if we can show that with more surgery at that initial surgery, if that avoids a recurrence hopefully, that patient can avoid having to undergo repeated vulvar surgeries or needing to have subsequent radiation treatment, which we know is also associated with a lot of side effects. So that's what we're hoping to see with a more personalized approach to cancer care. 

00:13:55 Sabrina 

That's great. It's great that there's positive impacts on both sides, seeing both the less aggressive cancers requiring less aggressive treatment and also the more aggressive ones getting extensive surgery or treatment that is needed. So that's great to see. Have you guys encountered any challenges or barriers, or do you foresee any, with implementing molecular-based surgical management in the real-world clinical setting? 

00:14:21 Amy 

Yeah, I mean, it's a great, great question. I guess widespread access to testing is always a concern when you're trying to implement a molecular stratified management plan. And is it going to be accessible to all patients globally? So it is a great question. Luckily, the molecular testing that is recommended for patients who have vulvar squamous cell carcinoma to differentiate between these different subtypes that we've been talking about, they're actually very simple tests. So essentially, it just requires two different immunohistochemistry tests. So something called P16, which is a marker that we use as a surrogate for the human papillomavirus infection and another immunohistochemistry test called P53. So just these two tests, and these tests are actually very cheap to perform. And they're actually, you know, they're simple tests and they're available in all pathology labs around the world. You know, it's they're tests that are done routinely in other tumor types. So it's not something that needs to be ordered in, you know, pathology labs should have access to these two tests. So, you know, essentially because these two tests are cheap and available in labs. This testing should be readily available to all our vulvar cancer patients now. And you know, this is something that is recommended to be performed, these two immunohistochemistry tests. It's recommended now by the World Health Organization pathology guidelines that all patients who have been diagnosed with a vulvar squamous cell carcinoma should have these two tests performed for all, you know, because it's so important in terms of that prognosis and providing a treatment plan for all the reasons we've talked about. So, you know, fortunately, because these tests are, yeah, cheap and available, I don't think widespread implementation is going to be a big concern. 

00:16:23 Sabrina 

That's great. That's great to hear that it won't be too much of a change in terms of the tests we already have available. Do you foresee, I guess you don't have the findings yet, but do you foresee that the findings from the STRIVE trial will influence guidelines or standards of care for vulvar cancer across Canada or beyond? 

00:16:42 Amy 

Yeah, we really hope so. You know, we are excited about the STRIVE trial because it's the first vulvar cancer trial that's been developed that uses this molecular stratified treatment approach for patients. So, once we, vulvar cancer is rare, and that's why this study does require not only participation across Canada, but also internationally as well, for us to get enough patients on the study to get the results that we need, but we are expecting that the results from the STRIVE trial will help inform vulvar cancer treatment guidelines, both within Canada, but also globally as well. And what we're really hoping is that it will change the standard of care, you know, for vulvar cancer patients. 

00:17:30 Sabrina 

Fantastic. I think all vulvar cancer patients will be very thankful for this work. Looking ahead, is there anything that excites you about where vulvar cancer research is headed in the future? 

00:17:44 Amy 

Yeah, I mean, I think really just, you know, everything that we've talked about, that we're finally moving away from having this frustrating one-size-fits-all treatment approach, which we know doesn't work well. Treating everyone the same is, you know, not the right approach. And the fact that we're finally moving to personalized cancer care for our vulvar cancer patients. And as you've already highlighted, You know, with this personalized care, hopefully we can decrease unnecessary treatments for vulvar cancer patients who we know have favorable outcomes, you know, and decreasing unnecessary treatment hopefully will reduce side effects associated with the treatment. But the flip side is we want to ensure that vulvar cancer patients who have aggressive disease are treated appropriately so we can improve their know, their vulvar cancer outcomes. So yeah, I think that's what excites me the most is that finally we're, yeah, we're moving towards this personalized cancer care, which I think will really benefit our patients. 

00:18:50 Sabrina 

Fantastic. Well, thank you so much for coming on the podcast today and sharing all of these details about such a fantastic study. And thanks for doing the study itself. 

00:19:00 Amy 

Yeah, thank you very much for having me. 

00:19:05 Outro 

Thanks for joining us on the GOSH Podcast. To learn more about the Gynecologic Cancer Initiative and our podcast, make sure to check out our website at gynecancerinitiative.ca.