Gynecologic oncology is a specialized field of medicine that focuses on

cancer Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. These contrast with benign tumors, which do not spread. Possible signs and symptoms include a lump, abnormal b ...

s of the female reproductive system, including

ovarian cancer Ovarian cancer is a cancerous tumor of an ovary. It may originate from the ovary itself or more commonly from communicating nearby structures such as fallopian tubes or the inner lining of the abdomen. The ovary is made up of three different c ...

uterine cancer Uterine cancer, also known as womb cancer, includes two types of cancer that develop from the tissues of the uterus. Endometrial cancer forms from the lining of the uterus, and uterine sarcoma forms from the muscles or support tissue of the uteru ...

vaginal cancer Vaginal cancer is an extraordinarily rare form of cancer that develops in the tissue of the vagina. Primary vaginal cancer originates from the vaginal tissue – most frequently squamous cell carcinoma, but primary vaginal adenocarcinoma, sarcoma ...

cervical cancer Cervical cancer is a cancer arising from the cervix. It is due to the abnormal growth of cells that have the ability to invade or spread to other parts of the body. Early on, typically no symptoms are seen. Later symptoms may include abnormal ...

, and

vulvar cancer Vulvar cancer is a cancer of the vulva, the outer portion of the female genitals. It most commonly affects the labia majora. Less often, the labia minora, clitoris, or vaginal glands are affected. Symptoms include a lump, itchiness, changes in t ...

. As specialists, they have extensive training in the diagnosis and treatment of these cancers. In the United States, 82,000 women are diagnosed with gynecologic cancer annually. In 2013, an estimated 91,730 were diagnosed. The

Society of Gynecologic Oncology The Society of Gynecologic Oncology (SGO), headquartered in Chicago, Illinois, is the premier medical specialty society for health care professionals trained in the comprehensive management of gynecologic cancers, affecting the uterus, fallopian ...

and the European Society of Gynaecological Oncology are professional organizations for gynecologic oncologists, and the Gynecologic Oncology Group is a professional organization for gynecological oncologists as well as other medical professionals who deal with gynecologic cancers
The Foundation for Women's Cancer
is the major U.S. organization that raises awareness and research funding and provides educational programs and materials about gynecologic cancers. There is low quality evidence which demonstrates women with gynaecological cancer receiving treatment from specialized centres benefit from longer survival than those managed in standard care. A meta analysis of three studies combining over 9000 women, suggested that specialist gynaecological cancer treatment centres may prolong the lives of women with ovarian cancer compared with general or community hospitals. In addition, a meta‐analysis of three other studies which assessed over 50,000 women, found that teaching centres or specialized cancer centres may prolong women's lives compared to those treated in community or general hospitals. Gynecological cancers comprise 10-15% of women's cancers, mainly affecting women past reproductive age but posing threats to fertility for younger patients. The most common route for treatment is combination therapy, consisting of a mix of both surgical and non-surgical interventions (radiotherapy, chemotherapy).

Risk factors

Obesity

Obesity is associated with an increased risk of developing gynecologic cancers such as

endometrial The endometrium is the inner epithelial layer, along with its mucous membrane, of the mammalian uterus. It has a basal layer and a functional layer: the basal layer contains stem cells which regenerate the functional layer. The functional layer ...

and

ovarian The ovary is an organ in the female reproductive system that produces an ovum. When released, this travels down the fallopian tube into the uterus, where it may become fertilized by a sperm. There is an ovary () found on each side of the body. T ...

cancer. For

endometrial cancer Endometrial cancer is a cancer that arises from the endometrium (the lining of the uterus or womb). It is the result of the abnormal growth of cells that have the ability to invade or spread to other parts of the body. The first sign is most o ...

, every 5-unit increase on the BMI scale was associated with a 50-60% increase in risk. Type 1 endometrial cancer is the most common endometrial cancer. As many as 90% of patients diagnosed with Type 1 endometrial cancer are obese. Although a correlation between obesity and

is possible, the association is predominantly found in low-grade subtypes of the cancer.

Genetic mutations

Genetic mutations such as the

BRCA1 Breast cancer type 1 susceptibility protein is a protein that in humans is encoded by the ''BRCA1'' () gene. Orthologs are common in other vertebrate species, whereas invertebrate genomes may encode a more distantly related gene. ''BRCA1'' is a h ...

and

BRCA2 ''BRCA2'' and BRCA2 () are a human gene and its protein product, respectively. The official symbol (BRCA2, italic for the gene, nonitalic for the protein) and the official name (originally breast cancer 2; currently BRCA2, DNA repair associated) ...

have been strongly linked to the development of ovarian cancer. The BRCA1 mutation has been shown to increase the risk of developing ovarian cancer by 36% - 60%. The BRCA2 mutation has been shown to increase the risk of developing ovarian cancer by 16% - 27%.

Human Papilloma Virus (HPV)

Human Papilloma Virus Human papillomavirus infection (HPV infection) is caused by a DNA virus from the ''Papillomaviridae'' family. Many HPV infections cause no symptoms and 90% resolve spontaneously within two years. In some cases, an HPV infection persists and res ...

(HPV) is a common sexually transmitted disease that has been associated with some gynecologic cancers, including those of the

cervix The cervix or cervix uteri (Latin, 'neck of the uterus') is the lower part of the uterus (womb) in the human female reproductive system. The cervix is usually 2 to 3 cm long (~1 inch) and roughly cylindrical in shape, which changes during ...

vagina In mammals, the vagina is the elastic, muscular part of the female genital tract. In humans, it extends from the vestibule to the cervix. The outer vaginal opening is normally partly covered by a thin layer of mucosal tissue called the hymen ...

, and

vulva The vulva (plural: vulvas or vulvae; derived from Latin for wrapper or covering) consists of the external sex organ, female sex organs. The vulva includes the mons pubis (or mons veneris), labia majora, labia minora, clitoris, bulb of vestibu ...

. A clear link between human papilloma virus and cervical cancer has long been established, with HPV associated with 70% to 90% of cases. Persistent human papilloma virus infections have been shown to be a driving factor for 70% to 75% of

vaginal In mammals, the vagina is the elastic, muscular part of the female genital tract. In humans, it extends from the vestibule to the cervix. The outer vaginal opening is normally partly covered by a thin layer of mucosal tissue called the hyme ...

and

Smoking

Smoking has been found to be a risk factor for the development of cervical, vulvar and vaginal cancer. Current women smokers are twice as likely to develop cervical cancer compared to their non-smokers counterparts. Several mechanisms have been researched to understand how smoking plays a role in the development of cervical cancer. The cervical epithelium's DNA has been shown to be damaged due to smoking. DNA damage levels in the cervix cells were higher in smokers when compared to non-smokers. It has also been postulated that smoking can lower the immune response to HPV as well as amplify the HPV-infection in the cervix. Through similar mechanisms, women smokers have also been found to be 3 times more likely to develop vulvar cancer. Smoking has also been associated with an elevated risk for vaginal cancer. Woman smokers are at double the risk for developing vaginal cancer when compared to women non-smokers.

Infertility

Infertility is a common disease affecting young adults. Some studies have shown that 1 in every 7 couples will fail to conceive due to infertility problems. Infertility is a known risk factor for gynecologic cancers. Infertile women are at a higher risk of developing ovarian cancer and endometrial cancer when compared to fertile women.

Signs and symptoms

Signs and symptoms usually vary depending on the type of cancer. The most common symptoms across all gynecological cancers are abnormal vaginal bleeding, vaginal discharge, pelvic pain and urination difficulties. Ovarian cancer * Bloating or abdominal swelling * Frequent urination * Pelvic or back pain * Increased satiety/loss of appetite * Altered bowel movements * Fatigue * Weight loss Endometrial cancer * Post-menopausal bleeding * Abnormal vaginal bleeding (heavy or irregular menstrual cycles) * Vaginal discharge * Difficulty urinating * Pelvic pain Vaginal cancer * Abnormal vaginal bleeding * Vaginal discharge * Pelvic Pain * Painful and frequent urination Cervical cancer * Abdominal pain * Foul-smelling vaginal discharge * Pelvic pain and/or back pain * Blood spotting * Post-menopausal bleeding Vulvar cancer * Pruritus: persistent itch in the vulva * Vulvar bleeding * Vulvar pain, soreness or tenderness * Burning sensation when urinating * A visible wart-like mass or sore on the vulva

Treatments

Ovarian cancer

The vast majority of cases are detected past point of metastasis beyond ovaries, implicating higher risk of morbidity and a need for aggressive combination therapy. Surgery and cytotoxic agents are typically required. Histology type is almost primarily epithelial, so treatments will refer to this subtype of pathology. Ovarian cancer is highly treatable with surgery for almost all cases with well-differentiated stage-1 tumour. Higher tumour grades may benefit from adjuvant treatment such as platinum-based chemotherapy. Optimal debulking is used to treat cases where cancer has spread to become macroscopically advanced. The goal of this procedure is to leave no tumour larger than 1 cm by the removal of significant portions of affected reproductive organs. Multiple interventions may be used to achieve optimal debulking, including abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, lymph node sampling, and peritoneal biopsies. There is a lack of randomized controlled trials comparing outcomes between chemotherapy and optimal debulking, so the current standard of care typically involves the sequential administration of both, beginning with surgical interventions. Interval debulking surgery may be employed halfway through chemotherapy following primary surgery if tumour remains above 1 cm in diameter. This has been shown to increase median survival of chemosensitive patients by up to 6 months. A second look laparotomy may be used to assess tumour status in clinical trials, but is not a staple of standard care due to a lack of association with improved outcomes. Fertility preserving surgery involves a thorough differential diagnosis to rule out

germ cell cancer Germ or germs may refer to: Science * Germ (microorganism), an informal word for a pathogen * Germ cell, cell that gives rise to the gametes of an organism that reproduces sexually * Germ layer, a primary layer of cells that forms during embry ...

or abdominal lymphoma, both of which resemble advanced ovarian cancer in presentation but are treatable with gentler methods. Fertility preserving surgery is one of the few cases where a second look laparotomy is recommended for caution. Platinum-based chemotherapy is paramount to treatment of epithelial ovarian cancer.

Carboplatin Carboplatin, sold under the trade name Paraplatin among others, is a chemotherapy medication used to treat a number of forms of cancer. This includes ovarian cancer, lung cancer, head and neck cancer, brain cancer, and neuroblastoma. It is used b ...

tends to fare better than

cisplatin Cisplatin is a chemotherapy medication used to treat a number of cancers. These include testicular cancer, ovarian cancer, cervical cancer, breast cancer, bladder cancer, head and neck cancer, esophageal cancer, lung cancer, mesothelioma, br ...

for side effects and use in outpatient setting in randomized clinical trials.

Paclitaxel Paclitaxel (PTX), sold under the brand name Taxol among others, is a chemotherapy medication used to treat a number of types of cancer. This includes ovarian cancer, esophageal cancer, breast cancer, lung cancer, Kaposi's sarcoma, cervical cancer ...

is a particularly effective add-on for late stage ovarian cancer. Some studies suggest that intraperitoneal chemotherapy may be advantageous over an intravenous route.

Cervical cancer

Cervical cancer is treated with surgery up to stage 2A. Local excision via loop cone biopsy is sufficient if detected in the earliest stage. If a patient presents beyond this point, bilateral lymphadenectomy is performed to assess metastasis to pelvic lymph nodes. If lymph nodes are negative, then excision of the uterus is performed. Otherwise, a combination of hysterectomy and radiotherapy is frequently employed. This combination approach may be substituted with chemoradiotherapy alone in some.

Endometrial cancer

Hysterectomy and bilateral oophorectomy is performed for early stage disease. More aggressive cases with lymphatic spread are often treated with radiotherapy. Hormone therapy is most commonly used to treat systemic spread, as endometrial cancer patients tend to be older and have other illnesses that make them poor candidates to withstand harsh cytotoxic agents used in chemotherapy. Minimal laparoscopic surgery is used for endometrial cancer more than any other gynecologic cancer, and may confer advantages over classical surgical interventions.

Vulvar cancer

Low incidence means that evidence-based therapy is relatively weak, but emphasis is placed on accurate assessment of cancerous tissue and reducing lymphatic spread. The minority of non-squamous histological subtypes do not typically require removal of the inguinal nodes. However, this is necessary to prevent spread in squamous cell carcinomas exceeding 1 mm in stromal invasion. If nodal disease is confirmed, adjuvant radiotherapy is administered.

Vaginal cancer

Treatment depends on the stage of vaginal cancer. Surgical resection and definitive radiotherapy are the first-line of treatment for early-stage vaginal cancer. Surgery is preferred over radiotherapy due to the preservation of the ovaries and sexual function as well as the elimination of the risk of radiation. For more advanced stages of vaginal cancer, external-beam radiation therapy (EBRT) is the standard method for treatment. External-beam radiation therapy involves the delivery of a boost to the pelvic side of the patient at a 45 Gy dose.

Epidemiology

* 1 in 70 women will develop ovarian cancer at some point in their life. Scandinavian countries have an incidence appropriately 6.5 times higher than that of Japan's. This is due to multifactorial reasons, both of genetic and environmental nature. * Cervical cancer makes up the largest percentage of gynaecological cancers. Women in developing countries tend to present with more advanced cases.

Quality of life

Sexuality

The experience of cancer influences the psychological aspect of sexuality, by posing a risk of developing barriers such as body image issues, low self esteem, and low mood or anxiety. Other barriers include changes to reproductive organs or sex drive as well as potential genital pain. Partners may also be affected by these changes in the relationship, especially with regards to intimacy and sexuality, which may in turn affect gynecological cancer patients by creating a perception of adverse relationship outcomes such as emotional distance or lack of interest.

References

External links

Foundation for Women's Cancer

British Gynaecological Cancer Society

British Gynaecological Cancer Society Meeting 2012

Gynecologic Cancer Treatment
{{DEFAULTSORT:Gynecologic Oncology Women's health