Gynaecological cancers

Gynaecological cancersThe Department of Health advises that most women with gynaecological cancer are managed by a sub-specialist team. The best evidence in medical literature suggests that women with gynaecological cancer do better if managed by a gynaecological oncology accredited surgeon, compared to a general gynaecologist or a general surgeon.

Cervical cancer

The uterus extends down towards the vagina, and this lower area is known as the cervix. Cells that make up the membrane lining the cervix can have a tendency to change over time, depending on several factors, such as infection with certain types of HPV virus. In rare cases, these mutated cells grow into larger, cancerous tumours.

Risk factors

The average probability of developing cervical cancer for women in the UK is around 0.5%. Women who fall into a higher risk bracket due to genetic or lifestyle factors may have an increased risk. You can check the criteria for each risk level here.

Age is an additional factor, since women aged 30-50 have an increased chance of presenting cervical cancer, although it is possible for women of any age.

Causes

One of the most common known causes of cell mutations that can later lead to cervical cancer is HPV (Human Papilloma Virus). A very large proportion (over 70%) of cancer cases of this type can be attributed to infection with both Type 16 and Type 18 HPV. Although there are dozens of other types, many do not have any impact on health.

Several types of HPV, including Types 16 and 18, are extremely common and easy to transmit via sexual contact. A greater number of sexual partners will increase the change of contracting these infections, as well any immune system deficiency. They have no symptoms generally, other than potentially causing cell changes in the female reproductive system.

Symptoms

Although there may not be any clear symptoms in the early stages of cervical cancer, testing as described above can highlight the presence of dysplasia while it is still microscopic. If the disease develops further, it may be indicated by vaginal bleeding between periods or after sexual intercourse, or other unusual vaginal discharge. It is also possible for the growths to start blocking the kidneys and surrounding area, which can be felt as back pain.

Treatment options

If the disease is identified earlier, there will be a wider range of treatment options, which is true of most cancers. If only a small area of the cervix is identified as cancerous, this can be taken out with a cone biopsy. This can slightly increase the changes of miscarriage in pregnant women, but it does not stop most women from having children later in life.

For more advanced stages of cervical cancer, a radical hysterectomy may be required. This involves removing the entire uterus and the surrounding tissue, which is a significant operation and can have come with some accompanying risks.

A trachelectomy may be a viable alternative, as this preserves the uterine body and does not cause infertility if successful, although again the chance of premature labour and miscarriage are increased. This procedure is still experimental and methods for carrying out a trachelectoy are still being developed.

Other than surgical solutions, it is common for chemotherapy and radiotherapy to be recommended, usually in conjunction with each other. These can both cause many serious side effects to general health in the short term, and also have a few potentially long term effects which can affect some patients.

Recurrence

In the unlikely event that cervical cancer returns after being treated, it usually means the cancer has reached a more aggressive stage, and this tends to increase the mortality rate significantly. However, surgery to remove the vagina and other organs in the lower part of the body may be able to prevent the disease from spreading in rare cases.

Recovery

If cancer of the cervix is treated quickly before it can reach a more serious stage, the vast majority of women do make a full recovery. After it has spread to other areas, however, there is a significantly lower chance that a patient will survive.


Ovarian cancer

The ovaries are the organs responsible for producing an egg for reproduction. They also produce hormones. A woman has two ovaries that are located on either side of the womb within the pelvis. Cancer of the ovaries is an overgrowth of abnormal cells from one of these organs. The most common type of cancer is termed ‘epithelial’ cancer and is an overgrowth of abnormal cells from the ovary lining. Other types can also exist such as an overgrowth of abnormal cells that produce hormones or eggs.

Incidence

Ovarian cancer occurs in about 1 in 80 women.

Age

Ovarian cancer is rare before the age of 40. It is most common around the age of 60.

Geographic

The disease has a similar incidence across the world with a slightly higher frequency in Western women.

Causes

The causes of most ovarian cancers are unknown. About five percent of women who develop ovarian cancer have a genetic predisposition. A defect in two genes called BRCA1 and BRCA2 have been identified that substantially increase a woman’s risk of developing breast and ovarian cancer. A woman with one of the BRCA genes may have up to a 40% lifetime risk of developing ovarian cancer while a woman with two first degree relatives (mother, sister or daughter) with ovarian cancer has a 15% lifetime risk of developing the disease. A woman with only one first degree relative has only a 1% increased risk.

Other factors have been associated with the development of ovarian cancer such as a condition called ‘endometriosis’ and the use of talcum powder. However, these associations have not been proven. The prolonged use of HRT probably does increase a woman’s risk of developing ovarian cancer although this increase is very small.
The disease is most common in women whose periods start early, end late, and who have few children. This has led some scientists to believe that the number of times a women produces an egg is related to the development of ovarian cancer.

Prevention

Women who take the oestrogen contraceptive pill for more than five years reduce their risk of ovarian cancer by half.
Screening for ovarian cancer has been developed to pick up the disease in it’s early stages. This involves an ultrasound scan and a blood test called ‘CA125’. The value of the screening is still controversial and large studies are currently underway examining this.

For women who have a ‘BRCA’ gene or a strong family history of ovarian cancer, they may choose to have their ovaries removed at the age of 40. This can be done through keyhole surgery and usually only involves two days stay in hospital. The operation results in an early menopause and there are a number of potential complication. It does not eliminate the risk of ovarian cancer as some cells are inevitably left behind. However, it does prevent 95% of all cancers.

Symptoms

Ovarian cancer often presents with non-specific symptoms. It can present as a large mass felt through the abdomen. Alternatively it can be found coincidentally on ultrasound scan. Often it presents with bowel symptoms, bloating or a feeling of distension.

Treatment

The mainstay of treatment for ovarian cancer is surgery and chemotherapy. Surgery usually involves removal of both ovaries, womb, and a piece of fatty tissue attached to the bowel called the omentum. Sometimes it is necessary to remove a piece of bowel resulting in a stoma (bag for faeces). However, investigations before the operation will give some idea as to how likely this is.

For women with very early disease, it is sometimes possible to remove just the ovary to preserve fertility. However it is important that the surgeon thoroughly examines the abdomen so other disease is not missed.

Chemotherapy often follows surgery and usually consists of a treatment every two to three weeks for six occasions. Different types of chemotherapy exist but the most common type does result in hair loss.

Recurrence

Recurrence of ovarian cancer is usually fatal eventually. Sometimes it can be treated with more chemotherapy and very occasionally when the recurrence has occurred in an isolated location, it is amenable to surgery. Sometimes recurrent ovarian cancer can cause blockage of the bowel and it may be necessary to bypass the blockage surgically for symptomatic relief.

Survival

If ovarian cancer presents early it is often curable with over a 90% cure rate. However, most cancers present in the later stages. For advanced ovarian cancer the average survival is about 3 and a half years for women who have treatment and less than a year for women who do not have treatment.


Endometrial/Uterine Cancer

Incidence

Occurs in about 1 in 100 women.

Age

Endometrial cancer is commonest in women in their mid to late fifties. It is rare before the age of 40.

Geographic

Womb cancer occurs in all countries. It is commonest in the USA and western countries but has an increasing incidence in Asian.

Causes

A hormone called ‘oestrogen’ that is naturally produced in the ovaries is thought to be associated with ‘endometrial cancer’. ‘Oestrogen’ is a component of hormone replacement therapy drugs and without the opposite drug (‘progesterone’) there is an increasing risk of womb cancer.

Womb cancer is also more common in women who are overweight, have no children, and who suffered from a condition called polycystic ovaries in the past. Women whose periods started at a young age and ended at an old age are also more likely develop womb cancer.

Overweight women are more likely to develop womb cancer as fat tissue produces ‘oestrogens’. Other conditions associated with being overweight such as hypertension and diabetes are also associated with the development of womb cancer.

Prevention

A healthy diet which is low in fat and sugar helps prevent against womb cancer as does regular exercise. There is no screening test for womb cancer but early presentation to a doctor when abnormal vaginal bleeding occurs normally results in its detection at an early stage.

Symptoms

Womb cancer usually presents as vaginal bleeding after a woman’s periods have stopped. It may also present before the periods have stopped as abnormal bleeding. ‘Uterine sarcomas’ often present as a lump that can be felt on the abdomen or with non-specific symptoms of bloating and change of bowel habit.

When a woman presents with abnormal bleeding the first investigation to occur is normally an ultrasound scan. Low ultrasound measurements of the thickness of the lining of the womb can exclude the possibility of ‘endometrial cancer’. Sometimes a small plastic device is used to take a biopsy from the womb lining. If there is still doubt as to the possible cause of any abnormal bleeding, a telescope is used to examine the lining of the womb. This test is called ‘hysteroscopy’.

Treatment

Treatment is initially by surgery with removal of the womb and ovaries. Sometimes it is necessary to remove the glands in the pelvis also.

A proportion of women also require radiotherapy. There are two types of radiotherapy commonly used. The first is vaginal radiotherapy where a probe is placed into the vagina for a period. This often occurs two or three times on separate occasions. The other type of radiotherapy is pelvic treatment where irradiation is used from the outside. This is used in more advanced forms of womb cancer and usually involves spending a period on the treatment couch daily for five or six weeks.

Chemotherapy is used for womb cancer when it has spread.

Endometrial Hyperplasia

‘Endometrial Hyperplasia’ is a condition of the womb that can lead on to cancer. It is diagnosed by examining a sample of the womb under a microscope and presents with similar symptoms to womb cancer. In its earliest form it is treatable with a drug called ‘progesterone’. It it’s more advanced form a hysterectomy is required.

Recurrence

Recurrent womb cancer has a poor prognosis. If a woman has a single site of recurrence at the top of the vagina it may be possible to excise it surgically or use radiotherapy if a woman has not had it already. Other treatments for recurrent womb cancer include chemotherapy and hormone treatment.

Survival

Most ‘endometrial cancers’ present early and are curable. If a woman has other illnesses such as diabetes or high blood pressure or if the woman is overweight, then surgery may be hazardous making the chances of a cure reduced. Advanced ‘endometrial cancer’ and most ‘uterine sarcomas’ have a poor prognosis.