Gynecologic Cancers

Current advances in the field of medicine have aided in the early detection and treatment of cancer, leading to an increased rate of survivorship among cancer patients after an initial diagnosis.

Human papilloma virus often lurks in cervical tissue, and it can cause cancer there. But the infection is also often benign, particularly among young women. Biomarkers of transformation are proving useful in helping cytologists to decide when a suspicious-looking Pap result is truly a sign of trouble.

As outlined in the excellent, comprehensive review by Drs. Liu and Matulonis, ovarian cancer is the most lethal gynecologic malignancy in the United States, with approximately 16,000 deaths and 22,000 new cases yearly.[1] The vast majority of patients present with intra-abdominal spread of disease at the time of diagnosis, resulting in low overall cure rates. As outlined, patients are primarily managed with primary surgical resection and subsequent platinum-based chemotherapy.

Epithelial ovarian cancer is the leading cause of death from gynecologic malignancy in the United States, with approximately 15,000 deaths per year. Platinum/taxane doublets have long been considered the standard treatment regimen for advanced-stage disease; however, recent studies have sought to improve on the outcome from this therapy. Intraperitoneal (IP) chemotherapy has been shown to yield superior progression-free survival (PFS) and overall survival (OS); however, logistical problems and toxicities have limited more widespread adoption. Recent studies have also suggested that a “dose-dense” schedule of paclitaxel in combination with carboplatin may result in improved outcomes, and the impact of biological therapies in the first-line setting is under active investigation. In the setting of recurrent disease, preliminary results suggest that novel doublet regimens such as carboplatin and pegylated liposomal doxorubicin may have similar activity to standard platinum/taxane doublets while carrying a reduced risk of allergic reactions. Additionally, targeted therapy remains an active area of investigation, with evidence of activity from agents such as PARP inhibitors, anti-angiogenics, and PI3 kinase inhibitors. Here, we review recent advances in our understanding of ovarian cancer and its treatment in both the newly diagnosed and recurrent settings.

After years of maintaining the status quo in ovarian cancer treatment, a number of recent advances have challenged the paradigm based on intravenous (IV) taxane and platinum as the therapy of choice for advanced ovarian cancer. These new data are summarized concisely by Liu and Matulonis in this issue.

The Society of Gynecologic Oncologists conducted a demographic and practice survey and found that their members are shifting away from private practice into salaried positions. The survey also found an increase in the number of group or multispecialty practices.

Once thought a risk for malignancy, septated ovarian cystic tumors are actually mostly benign. A study at the University of Kentucky changes the standard of care for those patients.

Citing different studies, two physicians reach different conclusions as to whether ovarian cancer screening is worthwhile.

Physicians must engage and educate patients about significant risk for cardiovascular disease.

Mrs. S. is a 37-year-old Caucasian female who sought care at her home institution overseas during a period of several months for complaints of esophageal reflux, constipation, early satiety, increasing abdominal girth, and fatigue.

Postmenopausal women at average risk of ovarian cancer may benefit from ROCA (Risk of Ovarian Cancer Algorithm), a new ovarian cancer screening strategy that combines information about trends in CA-125 blood test results and age, followed by transvaginal ultrasound (TVU) as needed and referral to a gynecologic oncologist. Results of a prospective multicenter trial of ROCA were reported at the 44th annual meeting of ASCO (abstract 5003). Results of ROCA testing were used to categorize women as low risk (requiring a repeat CA-125 test in 1 year); intermediate risk (repeat CA-125 test in 3 months); or high risk (TVU and referral to a gynecologic oncologist, who decides, based on clinical findings and the TVU result, whether the patient needs to undergo surgery).

Postmenopausal women who regularly use painkillers have lower estrogen levels, which could lead to a decreased risk of breast or ovarian cancer.

Of the predominant gynecologic cancers, cancer of the uterine cervix is the least common, with only 11,270 new cases anticipated in the United States in 2009. Nevertheless, approximately 4,070 women die of cancer of the uterine cervix annually in the United States.

Cervarix has won FDA approval for the prevention of cervical pre-cancers and cervical cancer associated with HPV-16 and HPV-18 for use in girls and young women (ages 10-25), according to GlaxoSmithKline.

The US Food and Drug Administration (FDA) has approved GlaxoSmithKline’s human papillomavirus bivalent (types 16 and 18) vaccine, recombinant (Cervarix) for the prevention of cervical precancers and cervical cancer associated with oncogenic human papillomavirus (HPV) types 16 and 18 for use in girls and young women (aged 10–25).

Comparative uptake of two radiotracers allows characterization of tumor.

Ovarian cancer is the most deadly gynecologic malignancy. In the US alone, an estimated 21,500 new cases will be diagnosed in 2009, and an estimated 14,600 women will die from this disease.

The Society of Gynecologic Oncologists (SGO) has published the first in a series of four papers on a variety of cervical cancer issues and topics that were the focus of its Forum “The Future Strategies for Cervical Cancer Prevention: What Do We Need to Do Now to Prepare,” held last September in Chicago.

The final analysis of the largest efficacy trial of a cervical cancer vaccine was published July 25, 2009, in The Lancet. The study, involving 18,644 women, confirmed GlaxoSmithKline’s Cervarix is highly effective at protecting against the two most common cervical cancer–causing human papillomavirus (HPV) types, 16 and 18. The study also showed that the vaccine provides cross-protection against HPV types 31, 33, and 45, the three most common cancer-causing virus types beyond 16 and 18.

Imaging with MR and/or PET/CT can help physicians figure out appropriate treatment for cervical cancer patients as well as prevent unnecessary therapy, according to a new study.

Endometrial cancer is the most common gynecologic malignancy, with an estimated 40,100 cases and 7,470 deaths in 2008. This malignancy represents 6% of all cancers, and 3% of cancer deaths in women. Endometrial cancer is more prevalent in older women, with an incidence of 1 in 142 for women 40 to 59 years old, increasing to 1 in 81 women over 70 years old.[1] Median age at diagnosis is 62.[2] The mortality of endometrial cancer has decreased from 4.18 to 4.12 per 100,000 from 1991 to 2004.

Published analyses combining groups of patients with different risk profiles have created confusion surrounding patient selection for adjuvant treatment after surgery for endometrial cancer. As a result, no randomized trial has demonstrated a survival benefit with the addition of adjuvant radiation

In this issue of ONCOLOGY, Diavolitsis et al have provided an excellent overview of the literature and state of our understanding of the role of adjuvant therapy in the treatment of endometrial cancer.

Results from an 8-year trial involving more than 130,000 women published in The New England Journal of Medicine (360:1385-1394, 2009) demonstrate that in low-resource settings, a single round of human papillomavirus (HPV) testing significantly reduces the numbers of advanced cervical cancers and deaths, compared with Pap testing or visual inspection with acetic acid (VIA). This was the first randomized controlled trial to measure incidence of cervical cancer and associated rates of death as the primary outcomes, using different tools for screening.

Diffusion-weighted MRI added to standard T2-weighted scans can help spot cervical cancer in its early stages. A preliminary study from the Institute of Cancer Research in London determined that DWI can spot tumors missed by T2 imaging and bolster management options for women who wish to preserve reproductive organs.