Prevention, Diagnosis and Treatment of Gynecologic Cancers

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1 Prevention, Diagnosis and Treatment of Gynecologic Cancers Jubilee Brown MD and Pamela T. Soliman MD, MPH Department of Gynecologic Oncology and Reproductive Medicine University of Texas MD Anderson Cancer Center 1

2 Judith Liebenthal Robinson Ovarian Cancer Foundation The JLR Foundation s mission is: (1) to educate the medical community as well as women on the signs, symptoms and the critical nature of early diagnosis of ovarian cancer; and (2) to fund research for effective screening and treatment of ovarian cancer.

3 What are Gynecologic Cancers? Abnormal growth of cells in the reproductive organs Each year in the United States more than 80,000 women 1 out of every 20 - are diagnosed with a cancer of the reproductive organs 3

4 Gynecologic Cancers

5 Gynecologic Cancers in U.S Uterine Cancer 49,560 new cases Ovarian Cancer 22,240 new cases Cervix Cancer 12,340 new cases 8,190 deaths 14,030 deaths 4,030 deaths Cancer Facts and Figures, ACS, 2007

6 Ovarian Cancer 6

7 Topics Ovarian cancer statistics Risk factors for ovarian cancer Signs and symptoms of ovarian cancer? Screening for ovarian cancer What should I be discussing with my doctor? Cancer Facts and Figures, ACS, 2007

8 Cancer statistics, 2013

9 Ovarian Cancer Gilda Radner Liz Tilberis Mean age 60 yrs Symptoms can be vague 70% of cases have advanced disease at the time of diagnosis Pap smear is NOT a screening test Most common cause of death among women with gynecologic cancers Madeline Kahn

10 Ovarian Cancer Risk Factors Increase Risk Family history Nulliparity Infertility Decrease Risk Multiparity Oral contraceptive pills Breast feeding Tubal ligation *Infertility medications have not been shown to increase risk of cancer

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12 Hereditary Breast Ovarian Syndrome 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Ovarian Bre ast General Population HBOC

13 Lynch Syndrome (HNPCC) Let your doctor know your family history of cancer 80% 70% 60% 50% General Population Genetic syndromes can significantly increase your risk for cancer 40% 30% 20% 10% 0% Ovarian Uterine Colon HNPCC women HNPCC men

14 Symptoms Bloating, increasing abdominal girth Fatigue Gastrointestinal disturbances Decreased appetite Urinary symptoms Abdominal/pelvic pain Unintended weight loss or gain

15 Challenges with Ovarian Cancer Screening Relatively uncommon cancer No known pre-cancer lesion No early symptoms No good test CA125 Ultrasound

16 Why is CA125 not Effective? Elevated in only 50% of stage I ovarian cancers Many other common conditions can falsely elevate fibroids, endometriosis, menses, post-abdominal surgery, liver disease false positives especially in pre-menopausal women

17 PLCO Screening Trial 78,216 women age years Screening arm - annual CA125 and pelvic U/S NOT able to pick up OC earlier Patients who had screening did NOT live longer False positives, n= underwent surgery 163 (15%) > 1 major complication

18 How Do We Diagnosis OC? Abnormality found during annual examination Persistent symptoms will often lead to a GI evaluation Eventually imaging studies will be performed Abnormal CA-125 Majority of women have Stage III/IV disease at the time of diagnosis

19 Treatment Surgical Tumor reduction Optimal Suboptimal Adjuvant chemotherapy Novel therapies for both upfront and recurrent disease

20 What Should I be Doing? Annual examination Pay attention to your body Abnormal bleeding Abdominal pain, bloating, changes in bowel habits Know your family history, if you are high risk consider genetic counseling or a high risk clinic Talk to your doctor

21 How to Choose the Right Doctor? Role of a specialist If an abnormality is found and there is a concern for cancer, consider evaluation and surgery by a cancer specialist

22 Types of Gynecologic Cancers n Ovarian Uterine (endometrial) Cervical Vulvar Vaginal Fallopian Tube

23 Uterine (Endometrial) Cancer 23

24 Reproductive System 24

25 Cancer Picture Warning! 25

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27 Uterine Cancer Facts Approximately 43,470 diagnosed and 7,950 deaths estimated for 2010* More common Less deadly Most common type of uterine cancer is endometrial cancer Begins in lining of the uterus (endometrium) * Jemal A et al, CA: J Can Clin,

28 Endometrial Cancer Symptoms Bleeding after menopause Irregular vaginal bleeding before menopause ANY ABNORMAL BLEEDING NEEDS TO BE EVALUATED 28

29 Any abnormal bleeding needs to be evaluated! 29

30 Any abnormal bleeding needs to be evaluated! 30

31 Evaluation of abnormal bleeding Usually in the office Pelvic ultrasound (sonogram) Endometrial biopsy (tiny straw into the uterine cavity through the vagina) Hysteroscopy / D and C if can t get enough information through the ultrasound and biopsy 31

32 Endometrial Cancer Risk Factors Obesity (3-4x) Lynch Syndrome (10-20x) Diabetes (2-3x) Late menopause Use of unopposed estrogen (9x) or tamoxifen (2-4 x) 32

33 Treatment of endometrial cancer Usually surgery Removal of uterus, cervix, tubes, and ovaries, and sometimes the lymph nodes Can usually be done with minimally invasive surgery Sometimes with hormones Sometimes requires radiation or chemotherapy after surgery 33

34 Cervical Cancer 34

35 Reproductive System 35

36 Uterus

37 Uterus Lies at top of vagina Pelvic exam only exocervix is visible Uterus, tubes, ovaries remain intraperitoneal

38 Warning! Cancer Picture! 38

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40 Cervical Cancer Facts Approximately 12,200 diagnosed and 4,210 deaths estimated for 2010* Only gynecological cancer that can be prevented by regular screening (Pap test) and vaccination Precancerous changes in the cervix do not typically cause any pain - must have pelvic exam and Pap test to detect early! * Jemal A et al, CA: J Can Clin,

41 It s only 4100 women 1000 were in Texas Average age = 45 years Average age death overall for US women = 79 years That makes 34 years x 4100 women = 139, 400 woman-years lost 41

42 It s only 4100 women 139, 400 woman-years lost If average income is $20,000, and 20 working years per person are lost because of death only, then $1, 640, 000 of wages are lost per year 42

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44 It s only 4100 women The kicker: Cervical cancer is a preventable disease 44

45 Cervical Cancer Symptoms Bleeding after intercourse Excessive vaginal discharge Abnormal bleeding between periods Means that screening hasn t caught it! MOST IMPORTANT: PAP / HPV TESTING!!! 45

46 Cervical Cancer Risk Factors Smoking High number of sexual partners Early age at first intercourse HIV and HPV infections Lack of access to medical care for routine Pap tests; no vaccination 46

47 Cervical Cancer Treatment Radical hysterectomy and lymph node removal Chemotherapy + radiation therapy Some (few) patients with early cancer can keep their fertility through a procedure called a radical trachelectomy (Cervix and surrounding tissues are removed; uterus is reconnected to vagina) 47

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49 Components of Robotic System n Console n Patient side cart n Vision system

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52 Human Papillomavirus (HPV) and >100 HPV types identified 1 Cervical Cancer oncogenic HPV types, including 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58 3 HPV 16 (54%) and HPV 18 (13%) account for the majority of worldwide cervical cancers Schiffman M et al. Arch Pathol Lab Med. 2003;127: Wiley DJ, Douglas J, Beutner K, et al. Clin Infect Dis. 2002;35(suppl 2):S210 S Muñoz N et al. N Engl J Med. 2003;348(6): Clifford GM. Br J Cancer. 2003:89(1);

53 Prophylactic Vaccines Give prior to exposure Protects against transmission and acquisition Viral like particle injected Gardasil - FDA approved 2006 Quadravalant vaccine (6, 11, 16, 18) Cervarix FDA approved 2008 Bivalent vaccine (16, 18) 53

54 GARDASIL (Merck) Quadrivalent human papillomavirus (HPV) 6/11/16/18 L1 virus-like particle (VLP) vaccine Aluminum adjuvant GARDASIL is given IM 3 times 0.5-mL doses - day 0, 2 mos, and 6 mos 100% protective for CIN2; 97% protective for CIN3 If unrestricted 57% CIN2, 45% CIN3 54

55 General Population Impact: HPV 16- or 18- Related CIN 2/3 or AIS N GARDASIL or HPV 16 L1 VLP Cases N Placebo Cases % Reduction 95% CI Prophylactic Efficacy* HPV 16 and/or HPV 18 Positive at Day 1 9, , % General Population 9, , % Impact *Includes all subjects who received at least 1 vaccination and who were naïve [PCR (-) and sero (-)] to HPV 6, 11, 16, and/or 18 at Day 1. Case counting started at 1 month Postdose 1. Includes all subjects who received at least 1 vaccination (regardless of baseline HPV status at Day 1). Case counting started at 1 month Postdose 1. Note: Table does not include disease due to nonvaccine HPV types. 55

56 Measure of success Incidence declined 76%, from 32.6 in the 1940 s to 7.9 in 1990 (whites) Incidence and mortality fell 4%/yr Decline has plateaued 56

57 Prevention and Early Detection- What You Can Do Annual physical exam, including vaginal and rectal exam and Pap test, even after menopause or hysterectomy Know your risk factors Be aware of early symptoms Remember that Pap test only detects cervical cancer 64

58 Prevention and Early Detection- What You Can Do Report any heavy, irregular or abnormal bleeding to your physician Pay attention to your body Discuss any persistent symptoms with your physician Consider birth control pills if at higher risk for ovarian cancer 65

59 Take Home Message Annual examination Pay attention to your body Abnormal bleeding Abdominal pain, bloating, changes in bowel habits Know your family history, if you are high risk consider genetic counseling or a high risk clinic Talk to your doctor

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