Gynecologic oncology

Last updated
Gynecologic oncology
Other namesGynecological cancer
Specialty OBGYN, oncology

Gynecologic oncology is a specialized field of medicine that focuses on cancers of the female reproductive system, including ovarian cancer, uterine cancer, vaginal cancer, cervical cancer, and vulvar cancer. As specialists, they have extensive training in the diagnosis and treatment of these cancers.

Contents

In the United States, 82,000 women are diagnosed with gynecologic cancer annually. [1] In 2013, an estimated 91,730 were diagnosed. [2]

There is low quality evidence which demonstrates women with gynaecological cancer receiving treatment from specialized centres benefit from longer survival than those managed in standard care. [3] A meta analysis of three studies combining over 9000 women, suggested that specialist gynaecological cancer treatment centres may prolong the lives of women with ovarian cancer compared with general or community hospitals. In addition, a meta‐analysis of three other studies which assessed over 50,000 women, found that teaching centres or specialized cancer centres may prolong women's lives compared to those treated in community or general hospitals.

Gynecological cancers comprise 10-15% of women's cancers, mainly affecting women past reproductive age but posing threats to fertility for younger patients. [4] The most common route for treatment is combination therapy, consisting of a mix of both surgical and non-surgical interventions (radiotherapy, chemotherapy). [4]

Signs and symptoms

Signs and symptoms usually vary depending on the type of cancer. The most common symptoms across all gynecological cancers are abnormal vaginal bleeding, vaginal discharge, pelvic pain and urination difficulties. [5]

Ovarian cancer [5] [6]

Endometrial cancer [5] [7] [8]

Vaginal cancer [9] [10]

Cervical cancer [5] [11]

Vulvar cancer [12] [13]

Risk factors

Obesity

Obesity is associated with an increased risk of developing gynecologic cancers such as endometrial and ovarian cancer. [14] For endometrial cancer, every 5-unit increase on the BMI scale was associated with a 50-60% increase in risk. [15] Type 1 endometrial cancer is the most common endometrial cancer. [16] As many as 90% of patients diagnosed with Type 1 endometrial cancer are obese. [17] Although a correlation between obesity and ovarian cancer is possible, the association is predominantly found in low-grade subtypes of the cancer. [18]

Genetic mutations

Genetic mutations such as the BRCA1 and BRCA2 have been strongly linked to the development of ovarian cancer. [19] The BRCA1 mutation has been shown to increase the risk of developing ovarian cancer by 36% - 60%. [20] The BRCA2 mutation has been shown to increase the risk of developing ovarian cancer by 16% - 27%. [20]

Human Papilloma Virus (HPV)

Human Papilloma Virus (HPV) is a common sexually transmitted disease that has been associated with some gynecologic cancers, including those of the cervix, vagina, and vulva. [21] A clear link between human papilloma virus and cervical cancer has long been established, with HPV associated with 70% to 90% of cases. [22] Persistent human papilloma virus infections have been shown to be a driving factor for 70% to 75% of vaginal and vulvar cancers. [22]

Smoking

Smoking has been found to be a risk factor for the development of cervical, vulvar and vaginal cancer. [23] [24] [25] Current women smokers are twice as likely to develop cervical cancer compared to their non-smokers counterparts. [23] Several mechanisms have been researched to understand how smoking plays a role in the development of cervical cancer. [26] The cervical epithelium's DNA has been shown to be damaged due to smoking. [26] DNA damage levels in the cervix cells were higher in smokers when compared to non-smokers. [26] It has also been postulated that smoking can lower the immune response to HPV as well as amplify the HPV-infection in the cervix. [27] Through similar mechanisms, women smokers have also been found to be 3 times more likely to develop vulvar cancer. [28] Smoking has also been associated with an elevated risk for vaginal cancer. [29] [25] Woman smokers are at double the risk for developing vaginal cancer when compared to women non-smokers. [29] [25]

Infertility

Infertility is a common disease affecting young adults. [30] Some studies have shown that 1 in every 7 couples will fail to conceive due to infertility problems. [30] Infertility is a known risk factor for gynecologic cancers. [31] Infertile women are at a higher risk of developing ovarian cancer and endometrial cancer when compared to fertile women. [31]

Diagnosis

Treatments

Ovarian cancer

The vast majority of cases are detected past point of metastasis beyond ovaries, implicating higher risk of morbidity and a need for aggressive combination therapy. Surgery and cytotoxic agents are typically required. [4] [32] Histology type is almost primarily epithelial, so treatments will refer to this subtype of pathology. [4] [32]

Ovarian cancer is highly treatable with surgery for almost all cases with well-differentiated stage-1 tumour. [4] [33] Higher tumour grades may benefit from adjuvant treatment such as platinum-based chemotherapy. [4] [33]

Optimal debulking is used to treat cases where cancer has spread to become macroscopically advanced. [4] [34] The goal of this procedure is to leave no tumour larger than 1 cm by the removal of significant portions of affected reproductive organs. [4] [34] Multiple interventions may be used to achieve optimal debulking, including abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, lymph node sampling, and peritoneal biopsies. [4] [34] There is a lack of randomized controlled trials comparing outcomes between chemotherapy and optimal debulking, so the current standard of care typically involves the sequential administration of both, beginning with surgical interventions. [4]

Interval debulking surgery may be employed halfway through chemotherapy following primary surgery if tumour remains above 1 cm in diameter. [4] [35] This has been shown to increase median survival of chemosensitive patients by up to 6 months. [4] [35]

A second look laparotomy may be used to assess tumour status in clinical trials, but is not a staple of standard care due to a lack of association with improved outcomes. [4] [36]

Fertility preserving surgery involves a thorough differential diagnosis to rule out germ cell cancer or abdominal lymphoma, both of which resemble advanced ovarian cancer in presentation but are treatable with gentler methods. [4] [37] Fertility preserving surgery is one of the few cases where a second look laparotomy is recommended for caution. [4] [37]

Platinum-based chemotherapy is paramount to treatment of epithelial ovarian cancer. Carboplatin tends to fare better than cisplatin for side effects and use in outpatient setting in randomized clinical trials. [4] Paclitaxel is a particularly effective add-on for late stage ovarian cancer. [4] Some studies suggest that intraperitoneal chemotherapy may be advantageous over an intravenous route. [4]

Cervical cancer

Cervical cancer is treated with surgery up to stage 2A. [4] [38] Local excision via loop cone biopsy is sufficient if detected in the earliest stage. [4] [38] If a patient presents beyond this point, bilateral lymphadenectomy is performed to assess metastasis to pelvic lymph nodes. [4] If lymph nodes are negative, then excision of the uterus is performed. [4] Otherwise, a combination of hysterectomy and radiotherapy is frequently employed. [4] This combination approach may be substituted with chemoradiotherapy alone in some. [4]

Endometrial cancer

Hysterectomy and bilateral oophorectomy is performed for early stage disease. [4] [39] More aggressive cases with lymphatic spread are often treated with radiotherapy. [40] Hormone therapy is most commonly used to treat systemic spread, as endometrial cancer patients tend to be older and have other illnesses that make them poor candidates to withstand harsh cytotoxic agents used in chemotherapy. [4] [40] Minimal laparoscopic surgery is used for endometrial cancer more than any other gynecologic cancer, and may confer advantages over classical surgical interventions. [4]

Vulvar cancer

Low incidence means that evidence-based therapy is relatively weak, but emphasis is placed on accurate assessment of cancerous tissue and reducing lymphatic spread. [41]

The minority of non-squamous histological subtypes do not typically require removal of the inguinal nodes. [4] [41] However, this is necessary to prevent spread in squamous cell carcinomas exceeding 1 mm in stromal invasion. [4] [41] If nodal disease is confirmed, adjuvant radiotherapy is administered. [4] [41]

Vaginal cancer

Treatment depends on the stage of vaginal cancer. [42] Surgical resection and definitive radiotherapy are the first-line of treatment for early-stage vaginal cancer. [42] Surgery is preferred over radiotherapy due to the preservation of the ovaries and sexual function as well as the elimination of the risk of radiation. [42] For more advanced stages of vaginal cancer, external-beam radiation therapy (EBRT) is the standard method for treatment. [43] [42] External-beam radiation therapy involves the delivery of a boost to the pelvic side of the patient at a 45 Gy dose. [42]

Prognosis

The experience of cancer influences the psychological aspect of sexuality, by posing a risk of developing barriers such as body image issues, low self esteem, and low mood or anxiety. [44] Other barriers include changes to reproductive organs or sex drive as well as potential genital pain. [44] Partners may also be affected by these changes in the relationship, especially with regards to intimacy and sexuality, which may in turn affect gynecological cancer patients by creating a perception of adverse relationship outcomes such as emotional distance or lack of interest. [45] [44]

Epidemiology

Society and culture

The Society of Gynecologic Oncology and the European Society of Gynaecological Oncology are professional organizations for gynecologic oncologists, and the Gynecologic Oncology Group is a professional organization for gynecological oncologists as well as other medical professionals who deal with gynecologic cancers. The Foundation for Women's Cancer is the major U.S. organization that raises awareness and research funding and provides educational programs and materials about gynecologic cancers.

See also

Related Research Articles

<span class="mw-page-title-main">Cervical cancer</span> Cancer arising from the cervix

Cervical cancer is a cancer arising from the cervix or in the any layer of the wall of the cervix. It is due to the abnormal growth of cells that have the ability to invade or spread to other parts of the body. Early on, typically no symptoms are seen. Later symptoms may include abnormal vaginal bleeding, pelvic pain or pain during sexual intercourse. While bleeding after sex may not be serious, it may also indicate the presence of cervical cancer.

<span class="mw-page-title-main">Hysterectomy</span> Surgical removal of the uterus

Hysterectomy is the surgical removal of the uterus and cervix. Supracervical hysterectomy refers to removal of the uterus while the cervix is spared. These procedures may also involve removal of the ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. The term “partial” or “total” hysterectomy are lay-terms that incorrectly describe the addition or omission of oophorectomy at the time of hysterectomy. These procedures are usually performed by a gynecologist. Removal of the uterus renders the patient unable to bear children and has surgical risks as well as long-term effects, so the surgery is normally recommended only when other treatment options are not available or have failed. It is the second most commonly performed gynecological surgical procedure, after cesarean section, in the United States. Nearly 68 percent were performed for conditions such as endometriosis, irregular bleeding, and uterine fibroids. It is expected that the frequency of hysterectomies for non-malignant indications will continue to fall given the development of alternative treatment options.

<span class="mw-page-title-main">Endometrial cancer</span> Uterine cancer that is located in tissues lining the uterus

Endometrial cancer is a cancer that arises from the endometrium. It is the result of the abnormal growth of cells that have the ability to invade or spread to other parts of the body. The first sign is most often vaginal bleeding not associated with a menstrual period. Other symptoms include pain with urination, pain during sexual intercourse, or pelvic pain. Endometrial cancer occurs most commonly after menopause.

<span class="mw-page-title-main">Ovarian cancer</span> Cancer originating in or on the ovary

Ovarian cancer is a cancerous tumor of an ovary. It may originate from the ovary itself or more commonly from communicating nearby structures such as fallopian tubes or the inner lining of the abdomen. The ovary is made up of three different cell types including epithelial cells, germ cells, and stromal cells. When these cells become abnormal, they have the ability to divide and form tumors. These cells can also invade or spread to other parts of the body. When this process begins, there may be no or only vague symptoms. Symptoms become more noticeable as the cancer progresses. These symptoms may include bloating, vaginal bleeding, pelvic pain, abdominal swelling, constipation, and loss of appetite, among others. Common areas to which the cancer may spread include the lining of the abdomen, lymph nodes, lungs, and liver.

<span class="mw-page-title-main">Anal cancer</span> Medical condition

Anal cancer is a cancer which arises from the anus, the distal opening of the gastrointestinal tract. Symptoms may include bleeding from the anus or a lump near the anus. Other symptoms may include pain, itchiness, or discharge from the anus. A change in bowel movements may also occur.

<span class="mw-page-title-main">Vaginal bleeding</span> Medical condition

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

<span class="mw-page-title-main">Cervical intraepithelial neoplasia</span> Medical condition

Cervical intraepithelial neoplasia (CIN), also known as cervical dysplasia, is the abnormal growth of cells on the surface of the cervix that could potentially lead to cervical cancer. More specifically, CIN refers to the potentially precancerous transformation of cells of the cervix.

Adjuvant therapy, also known as adjunct therapy, adjuvant care, or augmentation therapy, is a therapy that is given in addition to the primary or initial therapy to maximize its effectiveness. The surgeries and complex treatment regimens used in cancer therapy have led the term to be used mainly to describe adjuvant cancer treatments. An example of such adjuvant therapy is the additional treatment usually given after surgery where all detectable disease has been removed, but where there remains a statistical risk of relapse due to the presence of undetected disease. If known disease is left behind following surgery, then further treatment is not technically adjuvant.

<span class="mw-page-title-main">Vulvar cancer</span> Cancer involving the vulva

Vulvar cancer is a cancer of the vulva, the outer portion of the female genitals. It most commonly affects the labia majora. Less often, the labia minora, clitoris, or Bartholin's glands are affected. Symptoms include a lump, itchiness, changes in the skin, or bleeding from the vulva.

The Society of Gynecologic Oncology (SGO), headquartered in Chicago, Illinois, is the premier medical specialty society for health care professionals trained in the comprehensive management of gynecologic cancers, affecting the uterus, fallopian tubes, ovaries, cervix, vagina, and vulva. As a 501(c)(6) organization, the SGO contributes to the advancement of women’s cancer care by encouraging research, providing education, raising standards of practice, advocating for patients and members and collaborating with other domestic and international organizations.

Vaginal cancer is an extraordinarily rare form of cancer that develops in the tissue of the vagina. Primary vaginal cancer originates from the vaginal tissue – most frequently squamous cell carcinoma, but primary vaginal adenocarcinoma, sarcoma, and melanoma have also been reported – while secondary vaginal cancer involves the metastasis of a cancer that originated in a different part of the body. Secondary vaginal cancer is more common. Signs of vaginal cancer may include abnormal vaginal bleeding, dysuria, tenesmus, or pelvic pain, though as many as 20% of women diagnosed with vaginal cancer are asymptomatic at the time of diagnosis. Vaginal cancer occurs more frequently in women over age 50, and the mean age of diagnosis of vaginal cancer is 60 years. It often can be cured if found and treated in early stages. Surgery alone or surgery combined with pelvic radiation is typically used to treat vaginal cancer.

Gynecologic cancer is a type of cancer that affects the female reproductive system, including ovarian cancer, uterine cancer, vaginal cancer, cervical cancer, and vulvar cancer.

Ovarian diseases refer to diseases or disorders of the ovary.

Uterine clear-cell carcinoma (CC) is a rare form of endometrial cancer with distinct morphological features on pathology; it is aggressive and has high recurrence rate. Like uterine papillary serous carcinoma CC does not develop from endometrial hyperplasia and is not hormone sensitive, rather it arises from an atrophic endometrium. Such lesions belong to the type II endometrial cancers.

<span class="mw-page-title-main">Postcoital bleeding</span> Medical condition

Postcoital bleeding (PCB) is non-menstrual vaginal bleeding that occurs during or after sexual intercourse. Though some causes are with associated pain, it is typically painless and frequently associated with intermenstrual bleeding.

<span class="mw-page-title-main">Gynecologic cancer disparities in the United States</span>

Gynecologic cancer disparities in the United States refer to differences in incidence, prevalence, and mortality from gynecologic cancers between population groups. The five main types of gynecologic cancer include cervical cancer, ovarian cancer, endometrial cancer, vaginal cancer, and vulvar cancer. For patients with these and other gynecologic malignancies within the United States, disparities across the care continuum by socioeconomic status and racial/ethnic background have been previously identified and studied. The causes behind these disparities are multifaceted and a complex interplay of systemic differences in health as well as individual patient factors such as cultural, educational, and economic barriers.

<span class="mw-page-title-main">Squamous cell carcinoma of the vagina</span> Medical condition

Squamous cell carcinoma of the vagina is a potentially invasive type of cancer that forms in the tissues of the vagina. Though uncommonly diagnosed, squamous cell cancer of the vagina (SCCV) is the most common type of vaginal cancer, accounting for 80-90% of cases. SCCV forms in squamous cells, which are the thin, flat cells lining the vagina. SCCV initially spreads superficially within the vaginal wall and can slowly spread to invade other vaginal tissues. This carcinoma can metastasize to the lungs, and less frequently in the liver, bone, or other sites. SCCV has many risk factors in common with cervical cancer and is similarly strongly associated with infection with oncogenic strains of human papillomavirus (HPV).

Vaginal stenosis is an abnormal condition in which the vagina becomes narrower and shorter due to the formation of fibrous tissue. Vaginal stenosis can contribute to sexual dysfunction, dyspareunia and make pelvic exams difficult and painful. The lining of the vagina may also be thinner and drier and contain scar tissue. This condition can result in pain during sexual intercourse or a pelvic exam. Vaginal stenosis is often caused by radiation therapy to the pelvis, an episiotomy, or other forms of surgical procedures. Chemotherapy can also increase the likelihood of developing vaginal stenosis. Vaginal stenosis can also result from genital reconstructive surgery in people with congenital adrenal hyperplasia.

Bradley J. Monk is an American gynecologic oncologist, academician and researcher. He is a Professor on the Clinical Scholar Track in the Department of Obstetrics and Gynecology at the University of Arizona College of Medicine in Phoenix, Arizona, as well as at the Creighton University School of Medicine in Omaha, Nebraska. He also serves as Director of the Division of Gynecologic Oncology at the St. Joseph's Hospital and Medical Center in Phoenix.

<span class="mw-page-title-main">Ovarian squamous cell carcinoma</span> Medical condition

Ovarian squamous cell carcinoma (oSCC) or squamous ovarian carcinoma (SOC) is a rare tumor that accounts for 1% of ovarian cancers. Included in the World Health Organization's classification of ovarian cancer, it mainly affects women above 45 years of age. Survival depends on how advanced the disease is and how different or similar the individual cancer cells are.

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