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Home , Cervical cancer, Ovarian cancer, Uterine cancer

Conquering that Hit Below the Belt

Gregory Sfakianos, MD Gynecologic Oncologist Disclosures

None Objectives

• Define gynecologic cancers • Risk factors • Diagnosis • Treatment • Gynecologic Oncologist

• Physicians – Surgeons • Perform to manage cancers of the female . – Oncologists • – Administer chemotherapy – Manage side effects Gynecology

• Gynecologic cancers attack a 's reproductive organs – , , , , and .

• 105,890 women will be diagnosed this year

• 38,890 women will die this year

Prevalence of Gynecologic Cancers

Estimated New Cases

Others 5,670 7% Cervix 11,070 14% Uterine 40,100 51% 21,650 28%

Uterine is the most common.

American Cancer Society. Cancer Facts & Figures 2008. Atlanta, GA: American Cancer Society; 2008. 9 Gynecologic Cancer Deaths

Estimated Cancer Deaths

Others 1,630 6% Cervix 3,870 Uterine 14% 7,470 26%

Ovary 15,520 54%

Ovarian cancer is the most lethal.

American Cancer Society. Cancer Facts & Figures 2008. Atlanta, GA: American Cancer Society; 2008. 10 Gynecologic Cancer

• Cancer of the opening to the uterus (womb).

• Most common cause of cancer death in the world where Pap tests are not available

• Easiest gynecologic cancer to prevent through and early vaccination Cervical Cancer

• Rare in the U.S. secondary to Pap tests – Screening detects pre-cancerous changes – Approximately 11,270 cases are diagnosed yearly. • Caused by the Human – Very few HPV infections actually lead to cervical cancer – Most HPV infections are HPV

• A viral infection that can cause: HPV

• A viral infection that can cause: – Common HPV

• A viral infection that can cause: – Common warts – Genital warts HPV

• A viral infection that can cause: – Common warts – Genital warts – Precancerous lesions HPV

• A viral infection that can cause: – Common warts – Genital warts – Precancerous lesions – Cancer Common Infection

Infected with HPV Infection Is Sexually Transmitted Many Types of HPVs

Different HPVs–Different Infections Harmless No warts or cancer Warts-Linked Genital warts Cancer-Linked Most clear up Some persist, but no abnormalities in cervix Some persist, some abnormalities in cervix A few persist and progress to cervical cancer Cervical Cancer Risk Factors

• Women who have ever had sex • More than one sexual partner • Women whose partner (s) has had more than one sexual partner • Women who do not have Pap smears Cervical Cancer Risk Factors

• Immuno- suppressed patients including those who: – Use steroid medications on a regular basis – Organ transplant recipients – Are undergoing chemotherapy – Are infected with HIV

• Women who smoke. – all by itself increases the risk of HPV infection and cervical precancer lesions, and doubles the risk of getting cervical cancer Abnormal – How common is it?

10,000 cancers

300,000 HSIL (High-Grade precancerous lesions

1.25 million LSIL (Low-Grade precancerous lesions)

2-3 million ASC (Atypical Squamous Lesions

50-60 million women screened Abnormal Pap test- What next?

• - – Evaluation of the cervix with a microscope on a stand – • Negative - repeat Pap smear in 6 months • Precancerous changes- larger cervical biopsy What are the symptoms of cervical cancer? • Abnormal – Between periods – With intercourse – After • Unusual vaginal discharge • Other symptoms – Leg pain – – Bleeding from the rectum or bladder • Some women have no symptoms Cervical Cancer Treatment

• Surgery – Simple vs. Radical hysterectomy

• Radiation and Chemotherapy Cervical cancer: survival by stage

FIGO Stage 5-Year Survival

Stage I 81-96%

Stage II 65-87%

Stage III 35-50%

Stage IV 15-20%

• Fourth most common cancer affecting women

• Most common gynecologic malignancy

• Usually diagnosed early secondary to easy recognizable symptoms Uterine Cancer Risk Factors

• • Unopposed • Diabetes • • use • Nulliparity • Late menopause • Genetic risk factors Uterine Cancer Symptoms

• Postmenopausal bleeding

• Abnormal uterine bleeding

• Abnormal discharge

• Pelvic pressure Uterine Cancer Diagnosis

• Endometrial sampling – Office- – Operating room- D&C

• Hysterectomy Treatment

• Surgery – Total Hysterectomy – Surgical staging • Hormonal therapy • Radiation • Chemotherapy Uterine cancer: survival by stage

FIGO Stage 5-Year Survival

Stage I 85- 91%

Stage II 74- 83%

Stage III 50- 66%

Stage IV 20- 26% Ovarian Cancer

• 5th deadliest cancer in women • Majority of women diagnosed with advanced disease • Good initial response rates to therapy • Most patients develop recurrence and die within a few years Ovarian Cancer: Risk Factors • Increased Risk • Decreased Risk – Long history1 – Prophylactic surgery4,5 – Nulliparity2 – Oral contraceptive use4 – Talc3 – Increased parity4 – Family history of – Hysterectomy4 breast/ovarian cancer4 – Tubal ligation4 – Dietary factors4

1. American Cancer Society. Cancer Facts & Figures 2008. Atlanta, GA: American Cancer Society; 2008. 2. National Cancer Institute. Genetics of Breast and Ovarian Cancer. Revised 12/23/2008. 3. American Cancer Society. What Are the Risk Factors for Ovarian Cancer? Revised 01/19/2008. 4. Gates MA, Tworoger SS, Terry KL, et al. use, variants of the GSTM1, GSTT1, and NAT2 genes, and risk of epithelial ovarian cancer. Cancer Epidemiol Prev. 2008;17(9):2436-2444. 5. Fatouros M, Baltoyiannis G, Roukos DH. The predominant role of surgery in the prevention and new trends in the surgical treatment of women with BRCA1/2 . Ann Surg Oncol. 2008;15(1):21-33. 37 Ovarian Cancer Symptoms

• , • Increased abdominal girth • Abdominal discomfort • Early satiety • Urinary urgency or frequency • New onset and/ or Ovarian Cancer Diagnosis

• – Fluid removed from the abdomen

• Biopsy of mass

• Surgery Ovarian Cancer

• Treatment – Surgical staging – Maximal surgical – Chemotherapy • 6 cycles of based chemotherapy • Neoadjuvant chemotherapy – interval surgical debulking • Good option for poor surgical candidates Ovarian cancer: survival by stage

FIGO Stage 5-Year Survival

Stage I 83- 90%

Stage II 65- 71%

Stage III 20- 47%

Stage IV 10- 20% Questions?