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Gynecological Cancers - a Multidisciplinary Approach

Published on Jul 20, 2019 and last reviewed on Dec 23, 2022   -  3 min read

Abstract

Gynecological cancers are common among women, with timely detection, we can expect good cure rates. Appropriate treatment of these cancers involves doctors of various expertize.

Gynecological Cancers - a Multidisciplinary Approach

What Are Gynecological Malignancies?

Gynecological malignancies are among the common malignancies in females after breast cancer. As per the latest statistics, cervical cancer is the second most common cancer in women in India, with nearly 1 lakh new registrations happened in 2018. 1,46,420 new cases were registered last year with either of the common gynecological malignancies (cervix, ovary, or uterus). 5-year survival rates for localized cervical, ovarian, and uterine cancers are 91.8 %, 92.4 %, and 95 %; whereas those in case of node-positive cases are 56.3 %, 75.2 %, and 69 % respectively. In the case of distant metastasis, these rates drastically drop to 16.9 %, 29.2 %, and 16.8 % respectively. These rates reflect the importance of timely detection and treatment. 80 %, 36 %, and 89 % cases are either localized or node-positive, respectively.

These numbers demonstrate the obvious fact, that cervical and uterine cancers most commonly present at a stage where good cure rates are still possible, unfortunately, more often ovarian cancers present in the advanced stage. We have many guidelines which help us plan treatment for these malignancies. The most commonly employed guideline is NCCN (National Cancer Comprehensive Network), which gives accurate management decisions based upon the latest evidence.

As per the latest NCCN guidelines for cervical cancer, surgery is recommended only for early stages (FIGO stage IA and IB), for all other loco-regional cases, radiation with weekly concurrent platinum-based chemotherapy is the treatment of choice. Concurrent chemotherapy amplifies the effect of radiation and also has survival benefit.

Radiation is also recommended after surgery if the histopathological report is suggestive of adverse features such as positive margins, lymphovascular invasion, parametrium invasion, positive nodes, deep stromal invasion and size more than 4 cm (Sedlis criteria). There are multiple studies which have demonstrated the increased chances of recurrence if radiation is not given in the presence of such adverse features.

How Is Radiation Therapy Helpful in the Treatment of Such Malignancies?

Radiation therapy is delivered in two formats external beam radiotherapy (EBRT) and brachytherapy (BT).

  • EBRT is delivered over five weeks, usually 25 fractions or sittings, in which the patient lies down in supine position, similar to the positioning for a CT scan procedure. The radiation is delivered from the machine head called gantry, which can rotate 360 degrees and is capable of providing from different angles, while the patient lies still. Duration of EBRT during each sitting is usually not more than 10 minutes. With advances in technology, now EBRT can be delivered by minimizing the doses to urinary bladder and rectum, thus reducing the probability of radiation induced genitourinary and gastrointestinal side effects without compromising tumor control probability.
  • Brachytherapy is an inpatient procedure, where metallic tubes are placed inside the uterus, in which radiation source is placed with remote technology, thereby ensuring the safety of the personnel involved. This source then delivers radiation to the tumor, the effect of which is up to 2-3 cm from the tube (source), thus ensuring minimum side effects. Usually, 2 to 3 such sittings are required, depending upon response to EBRT, probability of side effects, patient’s age, etc.

What Are the Surgical Treatment Options?

Surgery is an essential treatment in the management of loco-regional uterine cancers. Usually, the recommended surgery is a hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic node dissection, or para-aortic nodal dissection, which depends upon baseline disease. It is very important that appropriate imaging (CT scan, MRI, or PET-CT) is done before proceeding towards surgery. Based upon adverse histopathological features, further radiation therapy and chemotherapy are recommended.

Adverse features include high grade, deep myometrial invasion, and lymphovascular invasion. In advanced stages, combination chemotherapy is recommended, usually 3 weekly for 6 cycles. The general principle being, to minimize the risk of local recurrence, radiation therapy is needed, whereas to mitigate systemic relapses, chemotherapy is required.

Ovarian malignancies are known for their advanced stage presentation. Usually, they are managed by surgery and combined chemotherapy. Role of radiation therapy is limited and still investigational.

Thus, for management of these malignancies is multimodality requiring the expertise of doctors of various knowledge inclusive of surgical, medical and radiation oncologists; also a good pathologist, radiologist, nuclear medicine expert is needed to provide the crucial information about the disease, thus helping in taking treatment decisions.

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Frequently Asked Questions


1.

Which Is the Most Common Cancer of Women’s Reproductive System?

Uterine cancer is the most common type of cancer found in women. According to the National Cancer Institute (NCI), it has the highest number of cancer cases (66,570) accounted in the United States. Uterine cancer, also known as endometrial cancer, accounts for 3.6 percent of all cancer cases.

2.

How to Identify Gynaecological Cancer?

Some warning signs and symptoms that help identify gynecological cancer include:
- Abnormal vaginal bleeding or discharge. 
- Bloating (feeling full too quickly or having difficulty eating).
- Pain or pressure in the pelvic region.
- Blood spots in between the periods.
- Urinary urgency (urge to urinate) and increase in frequency.
- Bleeding after menopause.
- Itching, burning, pain, and tenderness of the vulva (outer part of female genitalia.
- It is associated with changes in color or sores only in vulvar cancer.

3.

What Causes Gynaecological Cancer Mainly?

Gynecological cancer occurs in women's reproductive system (ovaries, uterus, fallopian tubes, and cervix). It is caused when the cells in the lining of these organs multiply abnormally and spread to adjacent parts.

4.

Which Group of People Have the Highest Risk of Developing Gynaecological Cancer?

Gynecological cancer can develop in any age group, irrespective of age, marital status, or habits. However, cancer is usually diagnosed in women aged 55 to 64 years. Women who are overweight or those having a family history have a higher tendency to develop reproductive organ cancers.

5.

What Factors Increase the Risk of Gynaecological Cancer?

Factors associated with gynecological cancer may be unique to particular reproductive organs. The various factors are as follows:
- Human Papillomavirus (HPV) Infection - Most cervical cancers are caused by HPV infection, mainly affecting women between 30 to 50 years. 
- Smoking - Women who smoke are at an increased risk of developing vaginal, vulvar, and cervical cancer. Smoking weakens the immune system, leading to persistent HPV infection.
- Post-Menopause - Cancers, such as ovarian, endometrial, and vaginal cancer, are mainly diagnosed in older women, especially post-menopausal.
- Family History - Women with a family history of endometrial or colon cancer are at an increased risk for ovarian and uterine cancer.
- Obesity - Women who are obese are at an increased risk of developing endometrial cancer.
- Diabetes - High blood sugar increases the risk of gynecological cancer, such as endometrial cancer.
- High Blood Pressure - High blood pressure or hypertension increases the risk of endometrial cancer.
- Diethylstilbestrol (DES) - Using DES hormone during pregnancy to prevent miscarriage increases the risk of vaginal cancer.

6.

Can Gynaecological Cancer Be Life-Threatening?

Some gynecological cancers are slow-growing, such as ovarian cancer. However, they can be fatal if not diagnosed early, before they spread to the nearby organs and lymph nodes. Ovarian cancer is a fatal gynecological cancer.

7.

How Does Ovarian Cancer Spread?

If not diagnosed early, Ovarian cancer can spread to adjacent organs, such as the liver, spleen, intestines, and sometimes even to the brain. Ovarian cancer starts in the fallopian tubes and quickly progresses from early stages to an advanced stage within a year.

8.

Which Test Are Used to Check for Gynecological Cancer?

A Pap test (Papanicolaou test) or Pap smear is a valuable screening tool to detect pre-cancer signs in the cervix and changes caused by human papillomavirus. A colposcopy can help examine the vulva, vagina, and cervix for signs of abnormal tissue growth.

9.

Can Cervical Cancer Go Undetected for Long?

Abnormal changes caused by cancer in the cervix can be slow and take years before it is detected. Cervical cancer does not exhibit any symptoms in the early stages. However, unusual discharge, itching, abdominal pain, or unexplained fatigue can be the early signs of cervical cancer.

10.

How to Identify Cancer in Private Areas?

Unusual bleeding or vaginal discharge can be early warning signals of cancer in women's reproductive organs. Pain or difficulty in urination and sexual intercourse can be other symptoms of vaginal cancer.

11.

Which Cancers Are the Most Fatal?

Lung cancer and bronchial cancer are known to be the deadliest of all cancers. These cancers have the lowest survival rate of 7.2 percent, with 130,180 deaths yearly. This is nearly three times the death caused due to colorectal cancer (52,580), the second most fatal cancer.

12.

How to Treat a Gynecological Cancer?

There are more than one treatment options to treat gynecological cancer.
They are as follows:
- Surgery - Involves removing the cancer tissues by excising them.
- Chemotherapy - Certain medicines are given as pills or in the veins to shrink or kill the cancer cells.
- Radiation - High-energy rays are used to kill cancer cells.
However, the treatment choice depends on the kind of cancer and its spread.

13.

Which Cancers Can Cause Back Pain?

Metastasis of cancer, such as breast, testicular, colon, and lung cancer to the spine, can cause backache symptoms. The pressure of tumors on the nerves in the back or spine can also cause pain in the back.

Last reviewed at:
23 Dec 2022  -  3 min read

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