Conquering Cancers that Hit Below the Belt Gregory Sfakianos, MD Gynecologic Oncologist Disclosures None Objectives • Define gynecologic cancers • Risk factors • Diagnosis • Treatment • Prognosis Gynecologic Oncologist • Physicians – Surgeons • Perform surgery to manage cancers of the female pelvis. – Oncologists • Chemotherapy – Administer chemotherapy – Manage side effects Gynecology Oncology • Gynecologic cancers attack a woman's reproductive organs – cervix, uterus, ovaries, fallopian tube, vagina and vulva. • 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 Ovary 51% 21,650 28% Uterine cancer 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 Cervical 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 screening 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 Papilloma Virus – Very few HPV infections actually lead to cervical cancer – Most HPV infections are asymptomatic HPV • A viral infection that can cause: HPV • A viral infection that can cause: – Common warts 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. – Smoking all by itself increases the risk of HPV infection and cervical precancer lesions, and doubles the risk of getting cervical cancer Abnormal Pap test – 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? • Colposcopy- – Evaluation of the cervix with a microscope on a stand – Biopsies • Negative biopsy- repeat Pap smear in 6 months • Precancerous changes- larger cervical biopsy What are the symptoms of cervical cancer? • Abnormal bleeding – Between periods – With intercourse – After menopause • Unusual vaginal discharge • Other symptoms – Leg pain – Pelvic pain – Bleeding from the rectum or bladder • Some women have no symptoms Cervical Cancer Treatment • Surgery – Simple hysterectomy 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% Uterine Cancer • Fourth most common cancer affecting women • Most common gynecologic malignancy • Usually diagnosed early secondary to easy recognizable symptoms Uterine Cancer Risk Factors • Obesity • Unopposed estrogen • Diabetes • Hypertension • Tamoxifen 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- endometrial biopsy – Operating room- D&C • Hysterectomy Endometrial Cancer 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 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 ovulation 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. Talc use, variants of the GSTM1, GSTT1, and NAT2 genes, and risk of epithelial ovarian cancer. Cancer Epidemiol Biomarkers 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 mutations. Ann Surg Oncol. 2008;15(1):21-33. 37 Ovarian Cancer Symptoms • Bloating, • Increased abdominal girth • Abdominal discomfort • Early satiety • Urinary urgency or frequency • New onset constipation and/ or diarrhea Ovarian Cancer Diagnosis • Paracentesis – Fluid removed from the abdomen • Biopsy of mass • Surgery Ovarian Cancer • Treatment – Surgical staging – Maximal surgical debulking – Chemotherapy • 6 cycles of platinum 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?.