Gynecological Cancer – 8
(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Thank you Chiragbhai for highlighting few other points about ovary cancer treatment.
1. Even stage 4 cancers can be treated with good prolongation of life and quality of life in many cases, including ovary and several others. We should give option and help patient and family to make a decision, rather than push our bias onto them. 2. Rising CA 125 without any symptoms or major findings on imaging, should be followed without treatment in most cases. 3. Chemosensitivity assays should not be used to determine which drug to give, especially in initial two to three lines of treatment decision making. 4. Oral chemotherapy and some targeted options are now available.
What is the next cancer that we are going to discuss? How about cancer of uterus? I recently heard in your cancer awareness talk about this cancer being associated with lifestyle. Is this true?
Answer: Yes that is true. Lifestyle changes, and obesity are two big known risk factors, the reasons why it is very common in USA. Also risk increases with age, especially post menopausal age. Lifestyle changes include mainly high fat diet, inadequate exercise, and factors leading to high estrogen. Later include early menarche, late menopause, less or no children, use of tamoxifen. If you have noticed, most of these are similar to risk factors for breast cancer as well. Additionally a small number of cases are hereditary, such as with HNPCC (Lynch syndrome). Patient should be referred to a genetic counselor if there is family history, including for colon cancer, or age below 50. This is important for both patient (as there is risk of other cancers), and for family members.
Que: Thank you for highlighting this. It is important for our readers also to understand that while so many people keep on reading minute details of what causes cancer and talk about so many unproven/unknown things like hair dye, cell phone, sugar intake etc, they seem to give less importance to the BIG FACTORS that we already know, and are largely in our hands. LIFESTYLE is associated with about 20% of cancers, TOBACCO 30% at least, ALCOHOL 5%.
Ans: Very true. This is what we should focus on for better chance in our fight against cancer.
Now let us get back to uterine cancer. There are no screening tests, but fortunately MOST PATIENTS PRESENT WITH POST MENOPAUSAL UTERINE BLEED, and are identified in early stages if this symptom is addressed promptly. Work up involves a uterine biopsy, which is generally sufficient. Some patients need D&C to make diagnosis. Staging work up includes a CT scan of abdomen and chest xray in early cases. In more advance cases, CT chest or a PET-CT can be done. There are no tumor markers, but CA 125 may be elevated in some cases. There are two main types in terms of pathology: a. Epithelial – most common – endometrioid is the biggest subtype; less common ones are carcinosarcoma (MMT), serous, clear cell etc. b. Mesenchymal – less common – includes leiomyosarcoma, endometrial stromal sarcoma and others.
Other pathology factors important in treatment decision making are Depth of myometrial invasion, Grade of tumor, lymphovascular invasion.
Que: What are the treatment options?
Ans: SURGERY is the mainstay of treatment. Since most patients are diagnosed in localized stage, surgery including complete removal of uterus, fallopian tubes, ovaries, and regional lymph nodes is the first step. Need for additional treatment is decided based on pathology factors mentioned earlier. Some patients need additional Radiotherapy, and some need Chemotherapy too.
In very early cases, but with higher grade or certain adverse features like LVI, sometimes only brachytherapy (internal radiation ) is also sufficient.
ABOVE Recommendations are for most common subtype i.e. endometrioid or typically also known as uterine adenocarcinoma. For other less common, but more aggressive subtypes, i.e. serous, clear cell, MMT are treated with postoperative chemotherapy even in early stages.
One SPECIFIC ISSUE is patients who have undergone hysterectomy for some other reason, and on pathology there is incidental finding of cancer. Such patients need careful evaluation by a gynecological oncosurgeon preferably. With very early stage, low grade, and no adverse pathology factors, patient may be monitored. All others however, need additional imaging such as at least CT scan. If any residual disease or suspicion for the same, a repeat surgery should be considered strongly.
July 13th 2017.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org
Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. www.shyamhemoncclinic.com