What is being done in Australia to improve early diagnosis, treatment and survivorship of gynaecological cancers?
Australia was one of the first countries in the world, after the United States, to recognize Gynaecological Oncology as a subspecialty of Obstetrics and Gynaecology. Official recognition by the (then) Royal Australian College of Obstetricians and Gynaecologists (RACOG) occurred in 1985, and training in gynaecological oncology was introduced in 1987. It takes 3 years of subspecialty training, following training in general Obstetrics and Gynaecology, to become a Certified Gynaecological Oncologist of the (now) RANZCOG. Gynaecological oncologists work as part of a multidisciplinary team in Gynaecological Cancer Centres in all capital cities in Australia, and in Newcastle. Outreach clinics are held in some large country towns. Any woman with a gynaecological cancer should at least have a consultation with a gynaecological oncologist to ensure that the best treatment is being offered. Results of treatment for gynaecological cancer in Australia are comparable with the best in the world.
Early diagnosis of cervical cancer was improved when the National Cervical Cancer Screening Program was introduced in 1992, and this program has seen the incidence of cervical cancer fall by about 50%.
Early diagnosis of ovarian cancer remains an elusive goal, but research to find a screening test is ongoing. Research into many aspects of ovarian cancer is ongoing via the Australian Ovarian Cancer Study, a large multicentre study which has accrued about 1500 patients. It is one of the largest ovarian cancer studies in the world.
The Australian and New Zealand Gynaecological Oncology Group (ANZGOG) conduct important clinical trials in collaboration with other clinical trials groups around the world, including the Gynaecological Cancer Intergroup (GCIG).
Gynaecological Cancer Centres employ specialised psychologists, social workers and nurses to ensure that survivorship is appropriately addressed.
A lot of research is being done, but much more could be done with more financial resources. Money raised by the AGCF will be used to fund research, both through the ANZGOG clinical trials, and through laboratory research into the various cancers.
Endometrial Cancer FAQs
Yes. The risk of endometrial cancer is increased in patients who are chronically exposed to the female sex hormone oestrogen, which in postmenopausal women is produced in fat cells. The increasing incidence of obesity in the population has led to a corresponding increase in incidence of endometrial cancer.
Yes. Endometrial cancer is an important part of the bowel cancer linked syndrome known as Hereditary Nonpolyposis Colon Cancer Syndrome or HNPCC. The risk of developing endometrial cancer in patients with this syndrome is about 40%, which is also the risk of developing bowel cancer.
The typical symptom of endometrial cancer is abnormal vaginal bleeding. As most endometrial cancers occur in postmenopausal women, the bleeding is usually postmenopausal bleeding, which is always an alarming symptom for women, and usually leads to early diagnosis. If endometrial cancer occurs in premenopausal women, there may be bleeding between the periods or even just increasingly heavy periods. This is usually caused by hormonal imbalance, not by cancer, so diagnosis is often delayed in such circumstances.
No. Most postmenopausal bleeding is caused by lack of oestrogen, which causes atrophic changes (‘thinning”) in the vagina and endometrium. Hormone replacement therapy (HRT) is also a common cause. Endometrial cancer is responsible for only about 15% of cases.
The average age of menopause is around 52 years, but menstruation may continue until the late 50s, or stop in the early 40s. In the months before menstruation stops completely, bleeding should get progressively less frequent and less heavy. If bleeding is getting heavier or more frequent, it should be investigated, because this may be a symptom of endometrial cancer.
Yes. Some endometrial cancers respond very well to progesterone or anti-oestrogen hormones, and they are often tried in patients who have developed recurrent disease. Hormones are also used sometimes as initial treatment for young women who have developed an early endometrial cancer, but who would like to avoid a hysterectomy in order to retain their fertility.
Cervical Cancer FAQs
No. The two HPV vaccines, Gardasil and Cervarix, only protect against two of the 15 high-risk HPV viruses. These two viruses, types 16 and 18, are responsible for 70% of cervical cancers in Australia, but you must continue with Pap smear screening, because you may be exposed to one of the other 13 other high-risk viruses.
No. Some abnormal Pap smears are due to inflammatory changes in the cervix only, and most are due to precancerous conditions, that can be readily treated. Only a few, forming a minority, are due to cervical cancer.
No. It will only reliably diagnose cancer of the cervix, which is the lower part of the uterus. Cancer of the endometrium (which is in the upper part of the uterus) may shed cancer cells which can occasionally be seen on a Pap test. Ovarian cancer also only rarely cancer sheds cells which are picked up on a Pap test. This limitation applies even more to other screening tests for cervical cancer.
Many cervical cancers cause no symptoms, and are only diagnosed because of an abnormal Pap smear. The most common symptoms are bleeding after sexual intercourse or after menopause. An abnormal vaginal discharge may also occur.
If the cancer is diagnosed reasonably early, as most cases are, it is usually treated by surgery. If the cancer has spread outside the cervix, it will require radiation therapy. These days, radiation is given with weekly chemotherapy, so called chemoradiation.
The 5-year survival for cancer of the cervix depends on how advanced it is at the time of diagnosis, but overall is about 70%.
Ovarian Cancer FAQs
Because the symptoms are nonspecific and vague, and are commonly experienced by healthy women. They include bloating, indigestion, vague pelvic or abdominal pain, and fatigue. It is only when the symptoms persist for more than 3 or 4 weeks that the woman is likely to seek medical advice. In addition, the symptoms are usually associated with advanced disease.
The same symptoms may be present, but often early ovarian cancer does not produce symptoms, and is noted incidentally on a CT scan or ultrasound done to investigate some other problem.
Yes. At least 10% of ovarian cancers are inherited. The majority of hereditary ovarian cancers are caused by the BRCA 1 or BRCA 2 genes, which are also responsible for hereditary breast cancer. A woman with a BRCA1 mutation has about a 40% risk of developing ovarian cancer, while a woman with a BRCA 2 mutation has about a 10% risk.
No. There is no effective screening test for ovarian cancer. In women who have a BRCA mutation, the best way to prevent ovarian cancer is to have your family early, and then have your tubes and ovaries removed. This will also decrease the risk of breast cancer by about 50%. For women who have a BRCA mutation, a transvaginal ultrasound every 6-12 months is the best way to check that the ovaries are normal, but this does not completely eliminate the risk of developing ovarian cancer, and such surveillance is being investigated currently to assess its usefulness.
The CA 125 test is not reliable for screening because it is only elevated in about 50% of patients with early stage disease, so a lot of patients with curable cancer will have false-negative results. In addition, the test is elevated in a lot of common benign conditions, such as fibroids and endometriosis; so many women will have false positive results, particularly if they are premenopausal.
It is very useful for following the response to chemotherapy in patients with advanced disease, and in monitoring for recurrence in patients who are in remission. The test will usually be elevated some months before the onset of symptoms, so scans can be ordered to see where the cancer has recurred.
Cancer of the Vulva and Vagina FAQs
Unlike cervical cancers, which are virtually all caused by the HPV virus, only about 50% of cancers of the vulva and vagina are HPV related, particularly those cases that occur in premenopausal women.
Yes, but not to the same extent as it will for cervical cancer.
Ageing increases the risk of developing most cancers, and a woman who develops any of the common gynaecological cancers is most likely to be over 50. Apart from age, there are some other well established risk factors for the gynaecological cancers, but an individual woman may have none of these known risk factors. Similarly, a woman who does have known risk factors may never develop cancer.
Genes are tiny pieces of DNA that can transmit characteristics, including a predisposition to develop cancer, from one generation to the next. Some families are cancer-prone because at least one of the inherited genes has a fault (a genetic mutation). This faulty gene can be carried by males as well as females, and is passed from one generation to the next. The mode of inheritance is called autosomal dominance, which means that 50% of the children will inherit the abnormal gene. Only about 10% of cancers are inherited.
A woman’s risk of developing ovarian cancer and/or breast cancer is greatly increased if she inherits an abnormal BRCA1 or BRCA2 gene. Such a woman usually, but not necessarily, has a family history of these cancers. This highlights the importance of a woman knowing her family cancer history, and of a general practitioner taking a cancer family history. If a woman has a significant family history, she should be referred to a Hereditary Cancer Specialist for genetic counselling and possible genetic testing. If a BRCA1 or BRCA2 mutation is found, advice about early detection or prevention of these cancers will be given for the woman herself, and for other members of her family. A woman who has Ashkenazi Jewish ancestors is more likely to carry a faulty BRCA1 or BRCA2 gene.
A woman who has no known genetic risk has about a 1 in 70 or 1.4 percent chance of developing ovarian cancer during her lifetime. By contrast, a woman who inherits a BRCA1 gene mutation has about a 40% risk of developing ovarian cancer by age 70 years, and a 70-80% chance of developing breast cancer. For a woman who inherits a BRCA2 gene mutation, the risk is developing ovarian cancer is about 15 percent, and the risk of developing breast cancer about 60%.
The other major heritable gynaecological cancer is endometrial cancer. These cancers occur as part of the Lynch syndrome, which is also known as the hereditary non polyposis colorectal cancer syndrome (HNPCC). A woman with this syndrome has about a 40% risk of developing endometrial cancer, and a 40% risk of developing bowel cancer. She also has about a 10% risk of developing ovarian cancer.
For more information visit the US National Cancer Institute website.
A woman who is overweight or eating a high fat diet increases her risk of developing uterine and ovarian cancer, compared with a woman who has a healthy diet and weight. The obesity epidemic in Western countries is mainly responsible for the increasing rates of endometrial cancer in these countries. Fat cells are able to manufacture the female hormone, oestrogen, and constant stimulation of the endometrium with oestrogen causes endometrial hyperplasia, a precancerous condition, and eventually endometrial cancer. Obese women are also at an increased risk of the uncommon mucinous type of ovarian cancer.
The link between endometrial cancer and diabetes is mainly related to the link with obesity. Overweight women get both diabetes and endometrial cancer, and the main contributor is the excess oestrogen produced by the fat cells.
A woman is at slightly higher risk of developing ovarian cancer if she has:
- reached puberty early (menstruating before 12)
- never had children
- never used oral contraceptives
- had children when over the age of 30, or
- reached menopause after age 55
These associations are possibly due to an increase in the total number of ovulations in the woman’s life in these circumstances, and the degree to which ovaries can rest and recover from the break and repair of the surface of the ovary after ovulation. A healthy woman ovulates each month of almost every year between the onset and cessation of menstruation, unless pregnant, lactating, or using oral contraception.
The risk of endometrial cancer is increased when the endometrium is subjected to prolonged stimulation with oestrogen, without any progesterone. This is called “unopposed oestrogen”. Progesterone is produced by the ovary after ovulation, so conditions that are associated with lack of ovulation increase the risk of endometrial cancer. Such conditions include polycystic ovarian syndrome in young women, and menopause after the age of 55 years. Women who have a late menopause usually do not ovulate for the last few years, although still having periods.
Use of the oral contraceptive pill for 5 years or more decreases the risk of a woman developing endometrial cancer, because combined oral contraceptives contain oestrogens and progestagens, substances with progesterone-like actions. The combined pill also decreases the risk of developing ovarian cancer, because it prevents ovulation.
A woman’s risk of cervical cancer in particular, and to a lesser extent vaginal and vulvar carcinoma, overwhelmingly relates to her exposure to the sexually transmitted human papilloma virus (HPV). Any woman who has ever been sexually active, whether heterosexual or homosexual, is at risk of acquiring HPV infection.
Risk increasing behaviours include:
- early age of first intercourse
- unsafe sex – not requiring casual male partners to use condoms
- having multiple sexual partners
- having sex with a male who has had many sexual partners.
This last point means that it is possible for the woman to have only ever had one sexual partner, yet still develop HPV infection and cancer of the cervix.
The HPV virus is very prevalent in the population, particularly among adolescents and young adults, and most infections are quickly cleared by the body’s own immune system. Only persisting infection can cause cervical cancer.
Another lifestyle risk factor is smoking, which has become more common among women. Smoking is widely known to increase the risk of lung cancer, but smoking also significantly increases the risk of developing cancers of the cervix, vagina and vulva. This increased risk is related in part to the secretion of some of the carcinogens in cigarette smoke in the mucus of the cervix, and in part to a decrease in the body’s natural immunity.
A woman who has had a previous breast cancer has at least double the risk of developing ovarian cancer, and her risk quadruples if her breast cancer was diagnosed before the age of 40. Her risk is even higher if she has a family history of ovarian or breast cancer. If she took the drug tamoxifen to prevent or treat her breast cancer, she is at a two to threefold increased risk of developing endometrial cancer.
A woman who has been treated for cervical cancer or precancer [CIN] will be at increased risk of subsequently developing HPV related cancer of the vulva or vagina. She should continue to have regular vaginal Pap tests, even though her cervix has been removed.
Vulvar cancer in postmenopausal women is usually associated with a long history of chronic vulvar itching and scratching. The commonest cause of this irritation is a skin condition called lichen sclerosus, and a woman with this condition should have it actively treated to try to prevent vulvar cancer.
A woman treated with pelvic radiation, e.g. for cervical cancer, has an increased risk of developing another pelvic cancer 20-30 years later. The risk is very small, and significantly outweighed by the benefits of treating the cancer. Exposure to radiation is of particular concern in children and young adults. For example, use of CT scans to investigate something such as back pain, which is almost certainly not life threatening, has been common practice in the past, but a safer alternative is now available. Magnetic resonance imaging (MRI) does not involve x-rays and is not known to promote cancer.
The increasing incidence of obesity in the population has led to a corresponding increase in incidence of endometrial cancer.
A woman who has had a hysterectomy for some benign disease, such as fibroids, has a significantly lower risk of developing ovarian cancer. This is a consistent finding in many studies, although the exact reason for the benefit is not clear.