ALL GYNAE CANCERS
What is being done in Australia to improve early diagnosis, treatment and survivorship of gynaecological cancers?
Australia was one of the first countries in the world, after the United States, to recognize Gynaecological Oncology as a subspecialty of Obstetrics and Gynaecology. Official recognition by the (then) Royal Australian College of Obstetricians and Gynaecologists (RACOG) occurred in 1985, and training in gynaecological oncology was introduced in 1987. It takes 3 years of subspecialty training, following training in general Obstetrics and Gynaecology, to become a Certified Gynaecological Oncologist of the (now) RANZCOG. Gynaecological oncologists work as part of a multidisciplinary team in Gynaecological Cancer Centres in all capital cities in Australia, and in Newcastle. Outreach clinics are held in some large country towns. Any woman with a gynaecological cancer should at least have a consultation with a gynaecological oncologist to ensure that the best treatment is being offered. Results of treatment for gynaecological cancer in Australia are comparable with the best in the world.
Early diagnosis of cervical cancer was improved when the National Cervical Cancer Screening Program was introduced in 1992, and this program has seen the incidence of cervical cancer fall by about 50%.
Early diagnosis of ovarian cancer remains an elusive goal, but research to find a screening test is ongoing. Research into many aspects of ovarian cancer is ongoing via the Australian Ovarian Cancer Study, a large multicentre study which has accrued about 1500 patients. It is one of the largest ovarian cancer studies in the world.
The Australian and New Zealand Gynaecological Oncology Group (ANZGOG) conduct important clinical trials in collaboration with other clinical trials groups around the world, including the Gynaecological Cancer Intergroup (GCIG).
Gynaecological Cancer Centres employ specialised psychologists, social workers and nurses to ensure that survivorship is appropriately addressed.
Is enough research being done?
A lot of research is being done, but much more could be done with more financial resources. Money raised by the AGCF will be used to fund research, both through the ANZGOG clinical trials, and through laboratory research into the various cancers.
What is being done to increase survival rates?
Is the incidence of endometrial cancer increasing?
Yes. The risk of endometrial cancer is increased in patients who are chronically exposed to the female sex hormone oestrogen, which in postmenopausal women is produced in fat cells. The increasing incidence of obesity in the population has led to a corresponding increase in incidence of endometrial cancer.
Can endometrial cancer be inherited?
Yes. Endometrial cancer is an important part of the bowel cancer linked syndrome known as Hereditary Nonpolyposis Colon Cancer Syndrome or HNPCC. The risk of developing endometrial cancer in patients with this syndrome is about 40%, which is also the risk of developing bowel cancer.
What are the symptoms of endometrial cancer?
The typical symptom of endometrial cancer is abnormal vaginal bleeding. As most endometrial cancers occur in postmenopausal women, the bleeding is usually postmenopausal bleeding, which is always an alarming symptom for women, and usually leads to early diagnosis. If endometrial cancer occurs in premenopausal women, there may be bleeding between the periods or even just increasingly heavy periods. This is usually caused by hormonal imbalance, not by cancer, so diagnosis is often delayed in such circumstances.
Is all postmenopausal bleeding due to endometrial cancer?
No. Most postmenopausal bleeding is caused by lack of oestrogen, which causes atrophic changes (‘thinning”) in the vagina and endometrium. Hormone replacement therapy (HRT) is also a common cause. Endometrial cancer is responsible for only about 15% of cases.
What bleeding should be expected around the time of the menopause?
The average age of menopause is around 52 years, but menstruation may continue until the late 50s, or stop in the early 40s. In the months before menstruation stops completely, bleeding should get progressively less frequent and less heavy. If bleeding is getting heavier or more frequent, it should be investigated, because this may be a symptom of endometrial cancer.
Can hormones be used to treat endometrial cancer?
Yes. Some endometrial cancers respond very well to progesterone or anti-oestrogen hormones, and they are often tried in patients who have developed recurrent disease. Hormones are also used sometimes as initial treatment for young women who have developed an early endometrial cancer, but who would like to avoid a hysterectomy in order to retain their fertility
If I have had the HPV vaccine, will that guarantee that I don’t get cervical cancer?
No. The two HPV vaccines, Gardasil and Cervarix, only protect against two of the 15 high-risk HPV viruses. These two viruses, types 16 and 18, are responsible for 70% of cervical cancers in Australia, but you must continue with Pap smear screening, because you may be exposed to one of the other 13 other high-risk viruses.
Does an abnormal Pap smear mean I have cervical cancer?
No. Some abnormal Pap smears are due to inflammatory changes in the cervix only, and most are due to precancerous conditions, that can be readily treated. Only a few, forming a minority, are due to cervical cancer.
Will a Pap test diagnose any cancer in my genital tract?
No. It will only reliably diagnose cancer of the cervix, which is the lower part of the uterus. Cancer of the endometrium (which is in the upper part of the uterus) may shed cancer cells which can occasionally be seen on a Pap test. Ovarian cancer also only rarely cancer sheds cells which are picked up on a Pap test. This limitation applies even more to other screening tests for cervical cancer.
What are the symptoms of cervical cancer?
Many cervical cancers cause no symptoms, and are only diagnosed because of an abnormal Pap smear. The commonest symptoms are bleeding after sexual intercourse or after menopause. An abnormal vaginal discharge may also occur.
How is cervical cancer treated?
If the cancer is diagnosed reasonably early, as most cases are, it is usually treated by surgery. If the cancer has spread outside the cervix, it will require radiation therapy. These days, radiation is given with weekly chemotherapy, so called chemoradiation.
What is the cure rate for cancer of the cervix?
The 5-year survival for cancer of the cervix depends on how advanced it is at the time of diagnosis, but overall is about 70%
Why is ovarian cancer usually advanced at the time of diagnosis?
Because the symptoms are nonspecific and vague, and are commonly experienced by healthy women. They include bloating, indigestion, vague pelvic or abdominal pain, and fatigue. It is only when the symptoms persist for more than 3 or 4 weeks that the woman is likely to seek medical advice. In addition, the symptoms are usually associated with advanced disease.
Are there any symptoms of early ovarian cancer?
The same symptoms may be present, but often early ovarian cancer does not produce symptoms, and is noted incidentally on a CT scan or ultrasound done to investigate some other problem.
Can ovarian cancer be inherited?
Yes. At least 10% of ovarian cancers are inherited. The majority of hereditary ovarian cancers are caused by the BRCA 1 or BRCA 2 genes, which are also responsible for hereditary breast cancer. A woman with a BRCA1 mutation has about a 40% risk of developing ovarian cancer, while a woman with a BRCA 2 mutation has about a 10% risk.
Is there any way to screen healthy women for ovarian cancer?
No. There is no effective screening test for ovarian cancer. In women who have a BRCA mutation, the best way to prevent ovarian cancer is to have your family early, and then have your tubes and ovaries removed. This will also decrease the risk of breast cancer by about 50%. For women who have a BRCA mutation, a transvaginal ultrasound every 6-12 months is the best way to check that the ovaries are normal, but this does not completely eliminate the risk of developing ovarian cancer, and such surveillance is being investigated currently to assess its usefulness.
What about using the CA 125 blood test?
The CA 125 test is not reliable for screening because it is only elevated in about 50% of patients with early stage disease, so a lot of patients with curable cancer will have false-negative results. In addition, the test is elevated in a lot of common benign conditions, such as fibroids and endometriosis; so many women will have false positive results, particularly if they are premenopausal.
Does the CA 125 test have any role to play in the management of ovarian cancer?
It is very useful for following the response to chemotherapy in patients with advanced disease, and in monitoring for recurrence in patients who are in remission. The test will usually be elevated some months before the onset of symptoms, so scans can be ordered to see where the cancer has recurred.
Are cancers of the vulva or vagina caused by the HPV virus?
Unlike cervical cancers, which are virtually all caused by the HPV virus, only about 50% of cancers of the vulva and vagina are HPV related, particularly those cases that occur in premenopausal women.
Will the HPV vaccine decrease the incidence of cancers of the vulva and vagina?
Yes, but not to the same extent as it will for cervical cancer.