Gynecologic oncologists are specialists who care for women with cancers of the ovary, uterus, vagina, and vulva. After graduating from medical school, gynecologic oncologists complete a four-year residency as OB/GYN physicians. After residency, they complete a three-year fellowship in gynecologic oncology. During this specialized training, fellows learn to perform advanced pelvic surgery, surgery of the gastrointestinal and urinary tracts, and chemotherapy administration. They also learn the principles of radiation therapy. When all training is completed, gynecologic oncologists are board certified in OB/GYN and gynecologic oncology. When a woman with gynecologic cancer sees a gynecologic oncologist, all of her treatment – from start to finish – is carried out by one physician who has extensive training in women’s cancer care.
Unfortunately, to date, there are no reliable screening tests for ovarian cancer. However, serum tests are available to follow patients already diagnosed with ovarian cancer and determine how they respond to treatment. Some people have studied whether these tests would be good screening tests for ovarian cancer. The results show conclusively that these serum tests are not specific enough to be used for ovarian cancer screening. There is a new technology called proteomics that is currently being studied for ovarian cancer screening. Unfortunately, this technology won’t be available for widespread screening for many years.
One of the biggest concerns that patients have while receiving chemotherapy is that of nausea and vomiting. In the past, this problem was quite prevalent because of the chemotherapy agents used and lack of good, anti-nausea medications. Thankfully, many drugs have since been developed that can eliminate nausea caused by chemotherapy. These drugs are given prior to infusion of chemotherapy and continue for three to five days following treatment. Agents that have been the most successful in eliminating nausea are called three-5-hydroxytryptamine (or 5-HT3) inhibitors. These drugs block receptors in the brain that control nausea. If nausea continues to be a problem, other anti-nausea drugs may be added to the regimen. Fortunately, with current chemotherapy and anti-nausea drugs, nausea and vomiting are very manageable problems.
The first step is to do an appropriate cancer staging operation, which includes removal of the ovaries and all other involved tissues to optimally resect the cancer to a minimal amount. A gynecologic oncologist is best qualified to perform this surgery. For all patients, except those with very early ovarian cancer, chemotherapy is recommended after surgery. The cycles are usually three to four weeks apart and are recommended for six to eight courses. Most prescribe the current gold-standard combination chemotherapy of paclitaxel/carboplatin. At Memorial Health University Medical Center, we offer women the opportunity to participate in clinical trials to treat ovarian cancer. These trials are conducted through the national Gynecologic Oncology Group. In selected cases of recurrence, such as tumor isolated to certain nodes, radiation may be suggested. Finally, if large recurrences are seen on imaging studies, a “second look” operation may be needed to remove the affected areas.
In the United States, about 5,600 women die each year from cancer of the cervix. Since the advent of the Pap smear, death rates from cervical cancer have decreased markedly. If women have routine Pap smears, this type of cancer is more than 90 percent preventable. Based on this information, two organizations – the American Cancer Society (ACS) and American College of Obstetricians and Gynecologists (ACOG) – have published guidelines for Pap smears. Both the ACS and ACOG state that the first Pap smear should occur at age 21 or three years after a woman begins having sexual intercourse. Both organizations basically state that every woman should have a yearly Pap test until age 30, then have the test every two to three years as long as she has had three consecutive tests with normal results. The ACS recommends discontinuing at age 70 with three consecutive years of normal results. The ACOG says no discontinuation based on two caveats: Pap smear screening of women over age 65 would increase five-year survival by 65 percent. And, gland cell cancers occur twice as often in women within three years of a normal Pap. Women should adhere to the recommendations of their gynecologist. Most gynecologists recommend annual Pap smears.
Over a woman’s lifetime, the risk of developing epithelial ovarian cancer is approximately 1.8 percent. Fortunately, only five to seven percent of patients with epithelial ovarian cancer have an inherited form of the disease (meaning that most patients have a sporadic, non-inherited form of the disease). Determining ovarian cancer risk for women depends upon family history. For example, if only one first-degree relative (a mother or sister) has the disease, then a daughter’s risk of developing ovarian cancer at some time in her life is approximately 3 to 5 percent. However, if more than one first-degree relative or multiple family members in several generations (grandmothers, aunts, cousins, etc.) have either breast or ovarian cancer, then the risk of developing ovarian cancer might be higher. In fact, these patients may have an inheritable form of breast/ovarian cancer caused by mutations in the BRCA 1 and 2 genes. When visiting your physician, it is important to provide as much family history as you can.
We offer two types of clinical trials for cervical cancer patients. Both trials are offered through an organization called the Gynecologic Oncology Group (GOG). A phase II trial is used to evaluate a new drug or treatment, usually for a cancer that has come back or "recurred." A phase II trial has the advantage of being new and possibly better than previously used treatments. However, it also may not be as effective as other treatments. A phase III trial compares a “gold standard” treatment with a new treatment (usually one that has been previously evaluated in a phase II study). Several years ago, articles generated by the GOG established that radiation plus chemotherapy yielded better survival than radiation alone for advanced cervical cancer. Without such trials, we would not have developed a new gold standard. The primary advantage of participating in any clinical trial is to enhance our knowledge of cancer treatment and help us develop future treatments or cures.
Recurrence is when cancer returns after successful treatment. Several tools are used to follow patients with ovarian cancer. The basic principles of medicine include a history and physical exam, and most important, a pelvic exam. If a tumor marker, such as CA-125, was elevated prior to the operation and chemotherapy, and falls to normal, this test is an important tool to detect early recurrence. The CA-125 levels are elevated in over 80 percent of patients with the most common ovarian cancer. Most gynecological oncologists initially obtain this blood test at three- to six-month intervals. Slight elevations of the level are of little concern. We tell our patients not to be a CA-125 junkie. Occasionally, doctors may order periodic CT scans or other X-rays to detect recurrences. In addition to CA-125, other blood tests may be available in the future.
Cancer of the vulva (the outer, visible portion of the female genitals) is rare. It usually occurs in women over 50 years of age, but 15 percent of the time, cases appear in women under age 40. Patients usually have long term itching or feel a mass or tumor. A painful ulcer may be present. A persistent wart should arouse suspicion. Often, women delay seeking treatment for up to 16 months. Women should examine their vulva periodically with a mirror and talk to their doctor immediately if they suspect a problem. A doctor can confirm the diagnosis with a biopsy.
Itching of the vulva, or outside of the vagina, can occur throughout a woman’s lifetime. Often, the itching is the result of a yeast infection that can affect women at any age. Yeast infections can be treated with anti-fungal agents. However, if the itching persists, see your gynecologist for a thorough exam to rule out a pre-cancerous or cancerous disorder. Many times, women with persistent itching are embarrassed to discus it in detail with their physician. Instead, they simply ask for creams or ointments to treat it. However, it’s important to talk to your physician and have an examination to rule out cancer of the vulva. This is especially important for older women. Don’t be embarrassed. Your physician is here to help and he or she doesn’t mind answering your questions.
Bleeding or spotting six to 12 months after periods have stopped is abnormal. Possible causes include polyps, use of unopposed estrogen, use of tamoxifen (a drug given during breast cancer treatment), thinning of the vagina, or – the most serious cause – cancer of the lining of the uterus. This endometrial cancer is the fourth most common cancer in women. All post-menopausal women with bleeding should have an endometrial biopsy to rule out cancer. Some physicians also use an ultrasound to evaluate the endometrial thickness. It is not enough to simply have a Pap smear, as this test may miss as many as 50 percent of all endometrial cancers. The best way to accurately diagnose endometrial cancer is to perform a D&C (a procedure that removes tissue from the lining of the uterus for testing), with or without a hysteroscopy (a procedure that involves inserting a small scope into the uterus so the doctor can visualize the lining).
It is a blood test that checks for a protein called cancer antigen (CA) 125. The protein is made by some, but not all ovarian cancers. When a woman is diagnosed with ovarian cancer, physicians may check to see if she has an elevated CA-125 level prior to surgery and chemotherapy. By checking the levels throughout treatment, physicians can tell how well the treatment is working. A normal CA-125 level is less than 35. Several large studies have shown that checking for CA-125 as an ovarian cancer screening tool is not useful. The reason is that many other non-cancerous diseases can also cause abnormal levels of CA-125.
An ovarian cyst can usually be felt during a pelvic examination or seen on an ultrasound or computerized tomography (CT) scan. In reproductive age women, most are functional cysts and are associated with ovulation. However, ovarian cancer can be found in as many as 20 percent of women with a persistent cyst. Women with persistent ovarian cysts should have an ultrasound or CT examination. In general, if the cyst is larger than a tennis ball, solid, cystic, associated with abdominal fluid, bilateral, or feels unmovable on pelvic examination, the physician will make a small incision and use a special scope to examine the cyst more closely. In women past menopause, a physician may test for elevated levels of CA-125 in the body when deciding whether or not to operate. For a very suspicious cyst, patients may be asked to consult with a gynecologic oncologist.
Human papilloma virus, or HPV, is the virus responsible for genital warts on the cervix (the narrow end of the uterus) and vulva (the outside of the vagina). There are more than 100 types of HPV, some of which can lead to cervical cancer. The HPV is spread through sexual transmission, affecting approximately 40 percent of the female population. Most infections do not result in any symptoms or findings of genital warts, but do result in abnormal Pap smear results. Fortunately, most infections go away on their own without any treatment. However, some infections do become chronic and require medical treatment of the cervix or vulva.
In the 1950s, Pap smear testing was introduced to screen or identify women at risk for cervical cancer. Over the years, the Pap smear has undergone many upgrades, making it one of the best screening tools for cancer. An abnormal Pap smear does not necessarily mean that a woman has cervical cancer. It does, however, suggest that a woman may have an infection or a pre-cancerous lesion. After an abnormal Pap smear, a physician may prescribe antibiotics, repeat the Pap smear, or move directly to a colposcopic evaluation. A colposcopy is a procedure that uses a magnifying glass to further examine the cervix. The exam helps to direct the physician if a biopsy of the cervix is necessary. As a screening tool, the Pap smear has drastically reduced the number of cervical cancer cases by finding problems in a pre-cancerous stage. This allows doctors to prescribe better fertility sparing treatments.