What is Gynecologic Cancer Gynecologic Cancers Marge Ramsdell RN, MN, OCN Madigan Army Medical Center Any cancer that starts in a woman s reproductive organs Each GYN cancer is unique 5 main types Cervical Ovarian Uterine Vaginal Vulvar 3/1/2018 1 3/1/2018 2 Who is at risk for GYN cancer? All women are at risk Risk generally increases with age Incidence estimated 2017 107,470 new cases 31,600 death (ACS, 2017) 3/1/2018 3 3/1/2018 4 1
Cervical Cancer - Facts 3 rd most common GYN cancer in women in the U.S. 2017 Estimated cases New 12,820 Deaths 4,210 Rates are decreasing in the U.S. Incidence remains high among Hispanic/Latino, Black, Asian women Persistent human papillomavirus (HPV) infection Most important risk factor The only GYN cancer that can be prevented with screening tests and routine follow-up 3/1/2018 5 Cervical Cancer Risk Factors Human Papilloma virus Smoking Carcinogens concentrate in cervical mucosa Immunosuppression STI s Chlamydia Genital herpes Multiple sexual partners Early onset of sexual activity Long term use of contraceptives Multiple full term pregnancies 3/1/2018 6 Human Papillomavirus (HPV) & Cervical Cancer Most significant risk factor Most common STI >100 types - most benign ~ 40 affect the genital tract Low-risk HPVs benign lesions/warts do not cause cancer HPV 6 & 11 90% of all genital warts High-risk HPVs can cause cancer HPV 16 & 18 Most infections occur without symptoms and go away HPV Vaccine 9-valent HPV vaccine HPV 6, 11, 16 & 18 Also covers HPV 31, 33, 45, 52 & 58 Cause ~ 15% of cervical cancers Recommendations Males 11 or 12 21 yrs Females 11 or 12 26 yrs May start at age 9 2 doses before 15 th birthday 3 doses after 15 th birthday Not recommended for women > 26 yrs (CDC.gov) 3/1/2018 7 3/1/2018 8 2
Screening Recommendations Age 21 Method and interval Cytology alone every 3 years HPV co-test every 5 years Discontinue screening Age 65 Adequate negative prior screening No history of CIN2 or > Not at high risk for cervical cancer Recommendation intended for general population Cervical Cancer - Pathophysiology Anatomy of the Cervix Endocervix Columnar epithelium Exocervix Squamous epithelium Squamo-columnar junction (SCJ) Transformation Zone Meeting point between endo & exo cervix Glandular cells replaced by squamous cells Response to hormonal changes Metaplasia 3/1/2018 9 3/1/2018 10 Cervical Cancer -Pathophysiology Major histological types Squamous 80% Adenocarcinoma 20% Premalignant changes Cervical intraepithelial neoplasia (CIN) Low grade CIN1 High grade CIN 2/3 Cervical Cancer Signs/Symptoms Frequently asymptomatic Most common Irregular/heavy vaginal bleeding Post-coital bleeding Advanced Pelvic/low back pain Bowel/urinary symptoms 3/1/2018 11 3/1/2018 12 3
Cervical Cancer Diagnosis Physical exam Visualization of the cervix Cervical cytology HPV testing Cervical biopsy and colposcopy With or without visible lesions Symptomatic without visible lesions Abnormal cervical cytology Cervical conization Cervical Cancer Staging Clinical vs surgical staging More accessible in low-resource settings Better for locally advanced disease Avoids surgery Procedure Physical exam Cervical biopsy Endoscopy Hysteroscopy, Cystoscopy, Proctoscopy Imaging studies 3/1/2018 13 3/1/2018 14 Invasive Cervical Cancer Staging Two system in use Federation of Gynecology and Obstetrics (FIGO) Most commonly used Stages - I IVA American Joint Committee on Cancer (AJCC) TNM Stages - T0 T4 In both systems the stages mean the same thing Cervical Cancer Treatment CIN 1 HPV/Cytology co-testing in 12 months CIN persisting at least 2 years Continued f/u or may treat Loop electrosurgical excision procedure (LEEP) CIN 2/3 Treatment required Excisional procedure (LEEP) or Ablation Cotesting at 12, 24 months Any abnormal test Colposcopy 3/1/2018 15 3/1/2018 16 4
Invasive Cervical Cancer - Treatment Choice of treatment will depend on Patient age Tumor volume Desire to maintain fertility Modes of treatment Surgery Radiation therapy Chemotherapy Invasive Cervical Cancer - Treatment Fertility sparing IA1 no lymphovascular space invasion (LVSI) Cone biopsy Trachelectomy IA1 with LVSI & IA2 Cone biopsy Trachelectomy + pelvic LND Consider sentinel lymph node mapping IB1 Radical trachelectomy + pelvic LND 3/1/2018 17 3/1/2018 18 Invasive Cervical Cancer - Treatment Early stage IA1/2 IB1 Non-Fertility Sparing IA1 no (LVSI) Cone biopsy Hysterectomy IA1 with LVSI & IA2 Modified radical hysterectomy + pelvic LND Consider sentinel lymph node mapping OR Pelvic External Beam Radiation (EBRT) + brachytherapy IB1 & IIA1 Radical hysterectomy + pelvic LND OR Pelvic EBRT + brachytherapy 3/1/2018 19 Invasive Cervical Cancer - Treatment Advanced Disease IB2 IVA IB2 & IIA2 Radical Hysterectomy + pelvic LND Majority treated with definitive chemoradiation Cisplatin-based regimen as single agent Combined with 5-FU External Beam RT Brachytherapy 3/1/2018 20 5
Cervical Cancer - Surveillance Interaval H&P 3-6 mo for 2 years 6-12 mo for 5 year Cervical/vaginal cytology annually Imaging Laboratory assessment Patient education Symptoms of recurrence Lifestyle Sexual health vaginal dilators & lubricants Long/late term effects of treatment 3/1/2018 21 3/1/2018 22 Ovarian Cancer - Facts Leading cause of death from GYN cancer. 5 th most common cause of cancer mortality Lifetime risk 1 in 75 New 22,240 Deaths 14,070 < 40% are cured Incidence increases with age Median age at diagnosis 63 > 60% present with advanced disease 5 yr. survival 64.5% 3/1/2018 23 Ovarian Cancer Risk Factors Patient Characteristics Age > 63 Personal hx breast Ca Reproductive factors Nulligravity Early menarche Late menopause Infertility Polycystic ovarian syndrome Endometriosis Genetic Family Hx ovarian Ca BRCA1/2 mutations Lynch syndrome Environmental factors Obesity Talc exposure Cigarette smoking 3/1/2018 24 6
Ovarian Cancer Decreased Risk Reproductive factors Use of oral contraceptives Pregnancy/nuliparity Breastfeeding Gynecologic surgery Salpingo-oophorectomy Tubal ligation Ovarian Cancer Screening Literature does not support routine screening UK Collaborative Trial of Ovarian Cancer Screening Prostate, Lung, Colorectal & Ovarian trial No significant reduction in mortality Women with high risk factors will be followed more closely Pelvic exam CA125 TransvaginalUltrasound 3/1/2018 25 3/1/2018 26 Ovarian Cancer Types Epithelial 90% Serous Endometrioid Mucinous Clear cell Germ Cell 3% Stromal 7% Ovarian Cancer Symptoms Gastrointestinal Bloating Urinary symptoms Difficulty eating/early satiety/ dyspepsia Nausea Constipation/Diarrhea Fatigue Back Pain Gynecologic Abdominal distention/increased abdominal girth Pelvic pain Menstrual irregularities Vaginal bleeding Watery discharge 3/1/2018 27 3/1/2018 28 7
Ovarian Cancer Symptoms 95% symptoms prior to diagnosis 89% symptoms with early stage disease Symptoms that persist daily > a few weeks Ovarian Cancer Diagnosis Hx of present illness Symptoms Family history HBOC Lynch syndrome GYN history Labwork Full panels plus CA-125 (consider HE4) B-HCG AFP Imaging Transvaginal ultrasound CT abd/pelvis MRI Chest x-ray Barium enema 3/1/2018 29 3/1/2018 30 Ovarian Cancer Treatment Risk-reducing surgery Primary treatment Surgical staging and debulking Laparotomy hysterectomy with BSO, omentectomy and lymphadenectomy Comprehensive staging Fluid sampling Pathologic assessment of the abdomen Goal optimal debulking Residual tumor < 1cm Improved response rates Longer disease free survival & overall survival 3/1/2018 31 Ovarian Cancer Treatment Chemotherapy Neoadjuvant benefit remains controversial Adjuvant therapy IV with or without intraperitoneal IV/IP regiment recommended for Stage III optimally debulked patients IV drugs - Paclitaxel, Doecetaxel, Carboplatin IP drugs Paclitexel, Cisplatin Number of cycles will vary with stage of disease 6 cycles total 3/1/2018 32 8
Ovarian Cancer Treatment Anti-Angiogenesis inhibitors Bevacizumab Question as to benefit in progression free survival Preferred option in pts with recurrent disease and ascities Ovarian Cancer Recurrence 50%-75% relapse with advanced disease Poor prognosis Pts who progress after 2 consecutive chemo regimens Those whose disease recurs in less than 6 mo. Considered platinum resistant Patient who relapse 6 mo or more Platinum sensitive Will often be treated with multiple courses 3/1/2018 33 3/1/2018 34 Ovarian Cancer Recurrence PARP Inhibitors BRCA gene mutation Typically used after 2 or more lines of therapy Oral agents Olaparib Rucaparib preferred for plantinum resistant pt Niraparib without germline BRCA mutation Ovarian Cancer Surveillance Follow up with physical exam Every 2-4 mo. for 2 yr Every 3-6 mo. for 3 yr Annually after 5 yr Other tests Imaging, lab work to include CA-125 Genetic risk evaluation Long term wellness care Physical symptoms/ treatment side effects Psychological issues Threat of recurrence 3/1/2018 35 3/1/2018 36 9