Gynecologic Cancers

Over the past 2 decades, we have seen major progress in the management of women with ovarian cancer, with improvements in both overall survival and quality of life. To truly appreciate this progress, it is important to understand the state of affairs regarding the treatment of ovarian cancer in the early 1980s. This paper will discuss that historical background, describe the increasingly favorable impact of evolving treatment paradigms in ovarian cancer, and note future directions for clinical research in this complex disease process.

Endometrial cancer is the mostcommon gynecologic malignancyaffecting women in theUnited States. In 1988, the InternationalFederation of Gynecology andObstetrics shifted from a clinical stagingprotocol to one based on surgicalfactors, making surgical staging theaccepted treatment approach to endometrialcancers, with excellentsurvival compared to other gynecologicmalignancies. The manuscript byKirby et al brings to light the controversiessurrounding the surgical evaluationof endometrial cancers. Althoughsurgical staging has been shown to haveboth prognostic and therapeutic benefit,major problems in the United Statescontinue to result in suboptimal treatmentof patients with endometrial cancer.These problems include the lack ofan accepted surgical protocol (in termsof adequacy of lymph node sampling)and incomplete surgical staging secondaryto patient factors or the lack ofreferral to specialty-trained gynecologiconcologists.

Kirby et al are correct in theirstatement that continued controversysurrounds the comprehensivesurgical staging of all patientswith clinical stage I endometrialadenocarcinoma. Such is the case becauselymph node metastasis is foundin only 10% of these patients. Theproportion of patients found to havelymph node metastasis is even loweramong those with grade 1 and 2 tumorswith minimal or no invasion. Ahigh proportion of patients with endometrialadenocarcinoma fall intothis group.

Early presentation of endometrial cancer permits effective managementwith excellent clinical outcome. The addition of hysteroscopy todilatation and curettage (D&C) in the evaluation of postmenopausalbleeding adds little to the detection of malignancy. Imaging studies suchas computed tomography, magnetic resonance imaging, and positronemissiontomography may be of use in determining the presence ofextrauterine disease in patients medically unfit for surgical staging.However, these studies are not sufficiently sensitive to replace surgicalstaging and have little role in routine preoperative evaluation. Clinicalstaging alone is clearly inadequate, as 23% of preoperative clinicalstage I/II patients are upstaged with comprehensive surgical staging.Preoperative tumor grade from D&C or office biopsy may be inaccurateand lead to an underestimate of tumor progression if used to determinewhich patients should be surgically staged. Clinical estimationof depth of invasion, with or without frozen section, is inaccurate andmay lead to underestimation of disease status when surgical staging isnot performed. The practice of resecting only clinically suspicious nodesshould be discouraged as it is no substitute for comprehensive surgicalstaging. Comprehensive surgical staging provides proper guidance forpostoperative adjuvant therapy, avoiding needless radiation in 85% ofclinical stage I/II patients. Finally, resection of occult metastasis withsurgical staging may improve survival.

The review by Vergote et al[1]presents a well-organized andcomprehensive summary of thedata addressing neoadjuvant chemotherapyfor ovarian cancer. The timingof debulking surgery for thisdisease is a common and clinicallyimportant question, but one that lacksdefinitive trial data. The assembleddata suggest a rationale for decisionmaking.The European Organizationfor Research and Treatment of Cancer(EORTC) and Gynecologic OncologyGroup (GOG) 152 trialspresent compelling evidence supportinga “maximal surgical effort” by anexperienced gynecologic surgeon,preferably at a specialty hospital, atsome point during primary therapy.

Neoadjuvant, or induction, chemotherapyhas been usedextensively in selected carcinomas,particularly head andneck cancer (recently reviewed inONCOLOGY)[1] and locally advancedbreast cancer. Despite beneficialeffects on morbidity, long-termsurvival has not been significantly improvedby neoadjuvant chemotherapy.

Primary debulking surgery by a gynecologic oncologist remains thestandard of care in advanced ovarian cancer. Optimal debulking surgeryshould be defined as no residual tumor load. In retrospective analyses,neoadjuvant chemotherapy followed by interval debulking surgerydoes not seem to worsen prognosis compared to primary debulking surgeryfollowed by chemotherapy. However, we will have to wait for theresults of future randomized trials to know whether neoadjuvant chemotherapyfollowed by interval debulking surgery is as good as primarydebulking surgery in stage IIIC and IV patients. Interval debulking isdefined as an operation performed after a short course of induction chemotherapy.Based on the randomized European Organization for Researchand Treatment of Cancer–Gynecological Cancer Group (EORTC-GCG)trial, interval debulking by an experienced surgeon improves survival insome patients who did not undergo optimal primary debulking surgery.Based on Gynecologic Oncology Group (GOG) 152 data, intervaldebulking surgery does not seem to be indicated in patients who underwentprimarily a maximal surgical effort by a gynecologic oncologist.Open laparoscopy is probably the most valuable tool for evaluating theoperability primarily or at the time of interval debulking surgery.

Few would question the statementthat the role of surgery in themanagement of epithelial ovariancancer is unique in solid tumoroncology.

The management of ovarian cancer entails a complex blend of medicaland surgical interventions. Managing patients with recurrent ovariancancer increases the complexity of therapies and adds palliative interventions.The presence of recurrent ovarian cancer is both emotionally andphysically taxing for patients as well as their caregivers. With an increasinglyinformed patient population, a balance must be achieved betweeneasily accessible information enabling patients to know that they nowhave an incurable disease and support for their hopes and desires to stillovercome their cancer. The decision tree in the management of recurrentovarian cancer blends many different factors. This discussion will separatethose factors as if they are pure elements. We will address managementbased on response to primary therapy and time to recurrence, thelocation of recurrence, symptoms of recurrence, the patient’s histopathology,and the patient’s primary stage as it relates to the extent of diseasepresent at the start of chemotherapy.

In their article, Drs. Michener andBelinson make the case for treatingrecurrent ovarian cancer as achronic disease, with limiting morbidityand providing palliation of symptomstheir major goals. A review ofrecent literature would support their contention and management strategy.The cure rate for patients with recurrentovarian cancer is < 5%, and theaverage patient in the United Statesreceives more than five separate regimensof chemotherapy for recurrentdisease. Previous attempts at aggressivetreatment for recurrent disease haveshown, at best, very modest benefitwith significant expense and morbidity.What we are left with is a strategy oftrying to determine which patients maybenefit from aggressive salvage therapyand which are better managed witha chronic palliative attempt.

The Michener/Belinson articledeals not so much with what isnew in the treatment of ovariancancer, but with the changing managementparadigm. The authorscorrectly point out that one cannotexpect to offer curative options inovarian cancer patients who recur.Consequently, in planning therapy,the focus should be on the ability toprovide a lifelong strategy to controlthe disease through maintenance therapy.After first-line chemotherapy,complete responders have reasonablylong remissions in the absence of anyintervening therapies, but this is notlikely to be the case with recurrentdisease. In fact, Markman et al[1] havestressed that remissions followingtreatment for recurrence are neverlonger than the preceding ones.

In this installment of Second Opinion, we are presenting two cases of tumors of the female genital tract, specifically, the ovary and uterus, which contain both epithelial and mesenchymal components and therefore have unique diagnostic and therapeutic implications. The first has an unusually poor prognosis and the second is notoriously difficult to diagnose.

Ovarian cancer is the deadliestof the gynecologic malignancies.Approximately threequartersof patients present with advanced-stage disease. With aggressivecytoreductive surgery followed byplatinum-based chemotherapy, mostpatients will achieve remission. Despitethis initially good response totreatment, most patients experiencerecurrence and ultimately die of theirdisease. Novel treatment strategies areneeded. Molecularly targeted therapiesoffer the promise of improvedefficacy with decreased toxicity. Inthis article, Drs. Stephanie Blank, RichardChang, and Franco Muggiapresent an excellent summary of thecurrent status of epidermal growth factorreceptor (EGFR) inhibitors in thetreatment of ovarian cancer. They describethe promise of these drugs aswell as some of the questions regardingthe best way to integrate theminto therapy for ovarian cancer.

The 14 reports in this special supplement discuss theuse of the cytoprotectant amifostine in patients withcancer of the head and neck, esophagus, lung, andcervix, as well as those with lymphoma and acutemyelogenous leukemia. Discussions focus on thepotential of this agent to both reduce radiation sideeffects such as xerostomia and permit doseescalation of chemotherapy and/or radiotherapy.Improvements in treatment outcome and quality oflife as a result of cytoprotection are examined.

The 14 reports in this special supplement discuss theuse of the cytoprotectant amifostine in patients withcancer of the head and neck, esophagus, lung, andcervix, as well as those with lymphoma and acutemyelogenous leukemia. Discussions focus on thepotential of this agent to both reduce radiation sideeffects such as xerostomia and permit doseescalation of chemotherapy and/or radiotherapy.Improvements in treatment outcome and quality oflife as a result of cytoprotection are examined.

SAN DIEGO-For the first time, a combination regimen has shown improved survival over single-agent cisplatin (Platinol) for the treatment of advanced cervical cancer, according to the Gynecologic Oncology Group (GOG) protocol 179, which was presented at the 35th Annual Meeting of the Society of Gynecologic Oncologists (abstract 9).

A review of sentinel node mapping in vulvar and cervical cancer, a technique intended to reduced lymphadenectomy-associated morbidity, and the related controversies.

Iwould like to compliment the authorson an excellent review ofsentinel node evaluation in gynecologiccancer-in particular, vulvarand cervical cancer. The authors havebeen at the forefront of minimally invasivesurgery for gynecologicmalignancies. They have publishedextensively about their experiencewith laparoscopy and radical trachelectomy.Now this group brings forthanother technique that may revolutionizethe way we treat women withvulvar and cervical carcinoma.

By a long-standing strategy,practitioners have sought tolessen the morbidity associatedwith the treatment of pelvic malignancies.With careful understandingof pathologic prognostic factors andthe natural histories of recurrence andmetastatic disease, as well as improvementof imaging studies, there hasbeen a significant reduction in the radicalityof gynecologic surgery.[1-3]

Cervical cancer rates have fallen in the United States; regardless, thedisease remains a significant concern for women, especially those whoare premenopausal. The management of cervical cancer is dependenton stage of disease at diagnosis, and specific needs emerge for patientsboth during and following treatment. Over the past decade, the focus hasbeen to maintain adequate tumor control while reducing long-termnegative consequences. However, problems with sexuality and fertilitypersist for women treated for cervical cancer despite these advances.Sexual dysfunction following treatment for gynecologic cancer hasbeen well documented in the literature, and recent studies demonstratethe success of brief psychosexual interventions. Treatment of sexualdifficulties in cancer patients can be achieved through the provision ofinformation, support, and symptom management, ideally as part of asexual health program. Resources are not always available to developsuch a program. However, medical professionals can identify individualsand organizations with expertise in treating sexual and fertilityconcerns, which can be provided to their patients, making help withthese problems more accessible as needs arise.

Carter et al provide a nice summaryof current knowledge ofsexual dysfunction in and rehabilitationof women with invasivecervical cancer. The prevailing perspectiveof their review, however,seems to be that most women treatedfor cervical cancer are white, middleclasspatients at major cancer centers.In order to make a difference in thequality of life of the majority of cervicalcancer survivors, we have to understandwho they are and recognizethe impact of social and gender inequalityon their lives and relationships.

The importance of quality of lifeduring and after treatment forcervical cancer has been ignoredfor too long. The pervasive attitudethat focuses on cure, withmorbidity an afterthought, is stillparamount in many patients’ and oncologists’minds. However, at the insistenceof patients and families, manyclinicians have recognized and startedto address these issues over thepast 2 decades.

NEW ORLEANS-In women with locally advanced cervical cancer, smoking is an independent risk factor for a significantly worse outcome, a new study from the Gynecologic Oncology Group (GOG) has shown.

ROCKVILLE, Maryland-Physicians can discontinue cervical cancer screening for many women age 65 and older, and delay screening for some young women until age 21, according to new guidelines developed by the US Preventive Services Task Force (USPSTF).

During 1973–1999, both the incidenceof and death rates forcervical cancer decreased byapproximately 50% in the UnitedStates. For 2002, approximately13,000 new cases of invasive cervicalcancer are expected, and approximately4,100 women will die of the disease.Although invasive cervical cancer canbe prevented by regular screening, theprevalence of Pap testing remains relativelylow among minority populationssuch as Hispanic women.