Gynecological Cancers Overview
Gynecological Cancers
Complexity of Cancer
Speaker: Katrine Bøttcher
Study Abroad in Scandinavia
Learning Outcomes
Types of Gynecological Cancers: Be familiar with the most frequent types.
Epidemiological and Etiological Factors: Awareness of important factors impacting gynecological cancers.
Staging: Ability to stage cancers according to the FIGO-staging system.
HPV and Cervical Cancer: Understanding the association between HPV and cervical cancer.
Screening Programs: Explain how screening programs help in the early detection of cervical cancer.
BRCA Mutation: Understand the role of BRCA mutations in ovarian cancer's etiology and treatment.
Variation in Treatment: Recognize how treatment varies with cancer type and stage.
Introduction
Normal Female Reproductive Anatomy
Components of the Female Reproductive System:
Uterine Tube
Ovary
Uterus
Cervix
Vagina
Labium Minus and Labium Majus
Greater Vestibular Gland
Rectouterine Pouch
Vesicouterine Pouch
Types of Gynecological Cancer
Cervical Cancer
Ovarian Cancer
Endometrial (Uterine) Cancer
Vaginal Cancer
Vulvar Cancer
Rare Types (e.g., myometrium, Bartholin's glands)
Case Presentations
Case 1: Jolene
Profile: 35-year-old female, presents with post-coital spotting, non-smoker.
History: Last pap smear 8 years ago, family history of uncle with prostate cancer.
Case 2: Tina
Profile: 64-year-old female, presents with bloating, early satiety, and mild nausea for 2-3 months, non-smoker.
History: Previously normal pap smears (last smear 2 years ago), family history of mother with breast cancer.
Considerations for Diagnostics
HPV vaccination status
Results of the last pap smear
Personal medical history
Parity and children
Details of family history
Comparison of Cases
Factor | Case 1: Cervical Cancer | Case 2: Ovarian Cancer |
|---|---|---|
Typical Age | 30-45 years | Median age at onset is 63 years |
Symptoms | Vaginal abnormal bleeding | Abdominal distension, vague GI symptoms |
Risk Factors | HPV-infection, smoking | Genetic mutations (e.g., BRCA), family history, age, nulliparity |
Screening Available? | Yes (pap smear, HPV) | No effective screening available |
Prognosis | Good due to screening | Poor due to late detection |
Epidemiology
Cervical Cancer:
Incidence: Denmark 1-2 per 100,000; USA 1.5-2 per 100,000
Mortality: Denmark 3-4 per 100,000; USA 3.3 per 100,000
Ovarian Cancer:
Incidence: Denmark 18-20 per 100,000; USA 26.5 per 100,000
Mortality: Denmark 5-6 per 100,000; USA 8 per 100,000
Endometrial Cancer:
Incidence: Denmark 15 per 100,000; USA 12.5 per 100,000
Mortality: Denmark 5-6 per 100,000; USA 8 per 100,000
Vaginal/Vulvar Cancer:
Incidence: Denmark 7-8 per 100,000; USA 6 per 100,000
Mortality: Denmark 2-3 per 100,000; USA 2.3 per 100,000
Comparisons of Cancer Mortality Rates
Ovarian cancer has a higher mortality than endometrial cancer due to fewer effective screening options and late symptom onset.
Decrease in cervical cancer mortality in Denmark due to screening and HPV vaccination.
Risk Factors
Cervical Cancer
HPV-infection
Genetic Factors: BRCA1/2 mutations
Chronic Conditions: Diabetes, Hypertension
Lifestyle Factors: Obesity, smoking, immune suppression
Ovarian Cancer
HPV-infection
Obesity
Genetic Mutations: BRCA1/2, family history
Nulliparity: Not having children
HPV Overview
Human Papillomavirus (HPV):
Causes both benign and malignant neoplasms, notably cervical cancer.
Over 100 types, with types 16 and 18 responsible for 70% of cervical cancers.
Commonly contracted during youth with most infections clearing by the immune system.
HPV Vaccination
Vaccination initiation dates:
Denmark: 2009 for girls, 2021 for boys
USA: 2006 for girls, 2011 for boys
Vaccination Rates:
Denmark: 85-90% girls; 65-70% boys
USA: 54-60% girls; 50-55% boys
Screening Program for Cervical Cancer
Changes in Screening Program: As of 2023, HPV testing alone is as effective as pap smear testing.
Denmark's Program:
Ages 23-29: Pap smear every 3 years
Ages 30-64: HPV testing every 5 years (positive -> pap smear)
U.S. Recommendations:
Ages 21-29: Pap smear every 3 years
Ages 30-65: Either pap smear every 3 years, HPV testing every 5 years, or combination every 5 years.
Symptoms and Presentation
Cervical Cancer
Early Symptoms:
Atypical vaginal bleeding (contact or inter-menstrual)
Atypical vaginal discharge
Late Symptoms:
Pain from mechanical pressure, symptoms from intestine or bladder involvement, general poor condition, weight loss, and anemia.
Ovarian Cancer
Late Diagnosis: 70-80% of patients present in advanced stages.
Common Symptoms:
Abdominal distension, heaviness, loss of appetite, nausea, fatigue, dyspnea, and possible deep venous thrombosis.
Diagnostic Process
Cervical Cancer
Approach:
Pap smear for abnormal cells, gynecological exam, biopsy for histological assessment, imaging for staging.
Ovarian Cancer
Approach:
Imaging, biopsy, tracking CA-125 levels, and genetic testing for treatment planning.
CA-125 Overview
CA-125 as a biomarker: Found in many ovarian cancer cells but also elevated in benign conditions; not suitable for screening due to low specificity and sensitivity.
BRCA1/2 Mutations
Function and Mutation Types:
Germline (hereditary) and somatic (acquired) mutations increase cancer risk.
Testing via blood sample and biopsy; hereditary mutations prompt family consulting.
Risk Assessment
Mutation Type | Lifetime Risk of Breast Cancer | Lifetime Risk of Ovarian Cancer |
|---|---|---|
BRCA1 | 56-87% | 20-60% |
BRCA2 | 28-85% | 10-27% |
FIGO Staging for Cervical Cancer
Stages:
Stage 0: Carcinoma in-situ
Stage 1: Confined to the cervix
Stage 2: Beyond cervix without pelvic wall/1/3 lower vagina
Stage 3: Disease reaches pelvic wall or lower 1/3 of vagina
Stage 4: Invades bladder/rectum or metastasis
5-Year Survival Rates
Stage | Survival Rate |
|---|---|
0 | 100% |
1 | 85% |
2 | 65% |
3 | 35% |
4 | 7% |
Treatment Overview
Cervical Cancer
Stage I: Surgery (local control)
Stages II-IV: Radiotherapy and chemotherapy for treatment, especially in advanced disease.
Ovarian Cancer
Standard Treatment: Surgery when possible, adjuvant chemotherapy, and tailored maintenance treatment for genetic profiles.
Prognosis
Cervical Cancer
Varies by stage:
Stage I: 96-98%
Stage II: 70%
Stage III: 45%
Stage IV: 15%
Ovarian Cancer
International survival rates:
Stage I: ~85%
Stage II: ~65%
Stage III: ~40%
Stage IV: ~20%
Key Prognostic Factors
Lymph node involvement, tumor size/spread, age, and socio-economic status influence outcomes.
Take Home Messages
Significance of Early Detection: Vital for improving survival; cervical cancer is typically caught early due to screening whereas ovarian cancer is often diagnosed late.
Correlation with HPV: Strong association with cervical cancer incidence decreasing due to HPV vaccination.
Variability in Treatment: Treatments differ widely based on cancer type and stage; surgery is primary for early-stage cervical cancer while chemotherapy is vital for ovarian cancer management.