Management of Gynaecological Cancers

Gynaecological Cancers in NSW

      1180 new cases in 2002 10% of all new cancer diagnoses Crude incidence rate 35.3 per 100,000 women 1:38 risk of developing gynaecological cancer 1 case per GP every 4 years 3 cases per gynaecologist each year

Epidemiology Of Gynaecological Cancers in NSW (2002) Cancer Type New cases

Cervix Uterus Ovary Breast 210 477 386 3981

Deaths (% of cancer deaths) Incidence Rate (per 100,000 women) Lifetime Risk

69 (1%) 101 (2%) 237 (4%) 885(16%) 6.3

14.3

11.6

119.2

1:218 1:85 1:124 1:11

Familial cancer risk and gynaecological cancer

   Family history is a recognised risk factor in breast, ovarian and colorectal cancer Endometrial cancer is often associated with non-polyposis colon cancer syndrome Patients identified as having a high risk of familial gynaecological cancer may benefit from referral to a specialised Familial Cancer Clinic

Cervical Cancer

    Cervical screening with regular, conventional Pap smears has proven to be an effective cancer screening strategy Most cervical cancers present in unscreened women Prognosis relates to stage at presentation Symptoms warrant investigation, regardless of Pap smear result

Management of Cervical Cancer

    Depends on stage of presentation Treatment often involves either surgery or (chemo)radiation or both The woman should be involved in treatment decisions Fertility preservation feasible for some (very) early stage disease

Management of Cervical Cancer (I)

 “Microinvasive”    Early stromal invasion Usually diagnosed after abnormal Pap smear Needs cone biopsy for accurate assessment  Cone biopsy    Minor surgical procedure Excises area for diagnosis Sometimes adequate treatment if minimal invasion and clear margins

Management of Cervical Cancer (II)

 “Early” disease    Stage I or early 2A Disease clinically confined to cervix No clinical metastases  (Chemo)radiation or surgery are options:   Radical hysterectomy and pelvic lymph node dissection External beam radiation with platinum chemotherapy and brachytherapy

Management of Cervical Cancer (III)

 Advanced disease  Stage 2B and greater  (Chemo)radiation :   External beam radiation with platinum chemotherapy and brachytherapy “Palliative” treatment for very advanced disease

Issues in cervical cancer

     Life threatening illness Fertility Menopause Sexuality Toxicity of treatment

Follow-up after treatment for cervical cancer

   After treatment, patients are usually followed closely as salvage treatment for localised recurrent disease may be beneficial Most recurrences occur within 2 years If the cervix remains in situ, follow up usually involves repeat cytology.

Cancer of the Uterus

    No effective screening strategy Early investigation of symptoms, especially PMB Clinical suspicion eg. Obesity, diabetes, chronic anovulation and infertility Delay in presentation worsens stage and prognosis

Management of Endometrial Cancer

   Attempt surgical resection (despite medical risks) Assess surgico-pathological risk factors Adjuvant (radiation) therapy for high-risk

Ovarian Cancer

    No effective screening test Symptoms often (? always) non specific Usually advanced at presentation Delay in diagnosis often perceived by patient

Management of Ovarian Cancer

      Assessment of pelvic masses “Risk of malignancy index” Surgical staging and debulking Surgery alone for early cases Chemotherapy for most High relapse and mortality rates

Management of Early Stage Ovarian Cancer

    Meticulous surgical staging Prognosis dependent on histopathologic features Sub-groups with high risk of recurrence Fertility sparing treatment appropriate in selected favourable cases

Follow-up after treatment of ovarian cancer

    Following completion of treatment, follow up usually involves clinical assessment and measurement of CA-125 The prognosis of recurrent disease is very poor, particularly if recurrence occurs soon after completing treatment The CA-125 is usually elevated prior to clinical recurrence Abnormal levels of CA-125 are a frequent cause distress and anxiety during follow up