There are three main types of gynaecological cancer:
- Cervical Cancer
- Endometrial Cancer
- Ovarian Cancer
With increasing awareness of these diseases and their symptoms and earlier diagnosis and treatment, there are better outcomes now than ever before.
Our service has a number of senior gynaecology cancer specialists who are able to take advantage of the latest advances in cancer diagnosis and treatment including fertility sparing surgery for younger women.
The incidence of cervical cancer is decreasing in the UK as a result of regular cervical screening. The incidence has fallen since 1989 when systematic screening was introduced and this disease now affects 2000 women in England and Wales each year. It mainly affects women in the 30 to 65 year old age group.
A considerable amount is known about how cervical cancer develops. The process is usually quite a long one covering many years. Initially, a women is infected with certain types of the human papiloma virus (HPV). It is very common to be infected with HPV and a vast majority of women have no problems subsequently. Their body fights the infection and eradicates it and they become immune to further infections. However, there is a group of women who are not able to adequately fight HPV and they then develop pre cancerous cells on the cervix, these cells can usually be detected by cervical smears and it is these abnormalities that screening is designed to detect.
These pre cancerous cells are called cervical intraepithelial neoplasia (CIN). CIN can be present for many years before developing into anything more severe. In fact, the vast majority of patients with CIN would not develop cervical cancer if they went untreated. However, if the CIN is undetected, usually for many years, then this can progress in about 30% of women to develop into invasive cancer of the cervix.
Other factors such as young age at the time of first intercourse, multiple sexual partners, smoking and the oral contraceptive pill have been associated with an increased chance of developing cervical cancer. However, the majority of women developing cervical cancer do not necessarily have any of these other possible risk factors.
Approximately 85% of cervical cancers develop from the cells that are on the surface of the cervix. This results in a squamous cell cancer. The other 15% of cervical cancers develop from the columnar epithelium which lines the inside of the cervix resulting in an adeno carcinoma of the cervix. Squamous cell carcinomas and adeno carcinomas are treated in exactly the same way.
A significant number of patients with cervical cancer will be detected during their routine cervical smear test. However, patients may present with abnormal irregular bleeding, especially after intercourse, or bleeding after the menopause. They may notice a smelly vaginal discharge or occasionally present with pain. On examination, a very small cervical cancer may not be visible to the naked eye, it may only be seen with a colposcopy examination or by taking a biopsy. The international organisation which classifies cervical cancers (FIGO) state that anyone with a cervical cancer should have an examination under anaesthetic, an examination of their bladder, an examination of the bowel (if necessary) and a scan of their chest and kidneys. All of these investigations can be utilised to determine exactly how large the tumour is and whether the tumour has spread to the surrounding tissues or to the lymph nodes of the pelvis. All patients will have an MRI scan which is the most accurate way of looking at the tumour.
Early cervical cancers can be treated with surgery. If the tumour is microscopic then it may be possible to remove it with a cone shaped biopsy of the cervix. Tumours that are smaller than 4cm and confined to the cervix will usually be treated with a radical hysterectomy. This is an operation which removes the uterus and the tissue to the side of the uterus which is called the parametrium. It also removes the upper one third of the vagina and the pelvic lymph nodes. It may or may not be necessary to remove the ovaries at the same time. A small tumour of the cervix which does not spread to the lymph nodes, which is treated by a radical hysterectomy stands a 95% chance of being cured.
Larger tumours of the cervix are usually treated with a combination of chemotherapy and radiotherapy. This treatment is just as effective as surgery in curing early stage cervical cancer. Radiotherapy is usually a five week course of external beam radiotherapy together with a further dose of internal radiotherapy at the end. A small dose of cisplatin chemotherapy is usually given at the beginning, half way through, and at the end of this treatment.
Once treatment is completed then patients are usually required to attend for follow-up examinations every three months for two years in the first instance. The chances of recurrent disease are very much decreased after two years.
Endometrial cancer tends to affect patients who have gone through the menopause, particularly those in the 65 to 75 year old age group. It is more common in patients who are overweight or who have diabetes or high blood pressure. It is more common in women who have had no children and less common in women who have been on the oral contraceptive pill. It is a disease which is more common in the Western world and has one of the highest incidences in the United States. Approximately 3000 women per year will develop endometrial cancer in England and Wales.
The majority of endometrial cancers arise from the columnar epithelium which lines the uterine cavity (endometrium). Over 85% of the tumours are adeno carcinomas and this histological sub type carries the best prognosis.
The vast majority of patients will present with an episode of vaginal bleeding after the menopause. Any episode of bleeding after the menopause requires investigation. Patients should undergo an abdominal and vaginal examination and a cervical smear should be taken. The lining of the uterus should be sampled. Sometimes this is possible in the outpatient department and sometimes the patient needs to come into hospital and have a hysteroscopy examination. All patients with post menopausal bleeding would have an ultrasound scan to look at the thickness of the lining of the uterus and to look at the ovaries. Any patient who has endometrial cancer diagnosed should have an MRI scan to look as closely as possible at the tumour. This scan is used to determine how deeply the tumour invades into the muscle layer of the uterus (myometrium).
Over 80% of women who develop endometrial cancer will present whilst that tumour is still confined to the uterus. Therefore, the correct treatment in almost all cases of endometrial cancer is to perform a hysterectomy operation. This can be performed either through an incision in the abdomen or very often through keyhole surgery. The keyhole surgery approach is particularly advantageous in the obese patients because it allows them to recover so much quicker. It may be necessary to remove some lymph nodes from the pelvis at the same time as the hysterectomy, but this is not a common procedure.
Approximately 40% of patients with endometrial cancer will be offered Radiotherapy treatment of the pelvis following their hysterectomy. The Radiotherapy is thought to decrease the chances of cancer recurrence. The need for Radiotherapy is determined by examination of the tumour and uterus under the microscope.
Generally speaking the prognosis from endometrial cancer is very good because the majority of patients present relatively early. Most patients are seen and examined at follow-up three monthly for the first two years and six monthly for two years after that. Their doctor may decide to take a smear from the top of the vagina as it is often the top of the vagina which is the commonest site for disease recurrence.
Ovarian cancer is the most common gynaecological cancer in women in the UK. If affects between 4,000 and 5,000 women every year. Unfortunately many of those women present when the disease is quite advanced and therefore the prognosis from ovarian cancer is often quite poor.
There is an increased chance of developing ovarian cancer in women who have had no children, a late menopause and sometimes in the event of a family history of ovarian cancer. There is a decreased chance of developing ovarian cancer in women who have been on the oral contraceptive pill and those who have already had hysterectomies with conservation of ovaries. Smoking appears to have no affect on the incidence of ovarian cancer.
Patients with ovarian cancer tend to present in a number of different ways. Some will find a mass in the abdomen which is causing swelling. Some will find fluid in their abdomen, which is also caused swelling and many will find a decreased appetite and a change in bowel habit. Some will have their ovarian cancer discovered coincidentally.
Quite a number of patients with ovarian cancer are actually referred by their GP to other specialists such as bowel surgeons and gastroenterologists because their symptoms can be so confusing. On examination a mass may be found in the abdomen, which arises from the pelvis. An ultrasound scan can usually characterise this matter and other scans such as MRI scan and CT scan may also be used to help in the diagnosis.
A blood test can be done to look for a CA125 level. If this is raised it increases the suspicion of an ovarian cyst being due to an ovarian cancer.
Most patients with ovarian cancer will require a combination of surgery and chemotherapy. It is most common to perform the surgery first to remove the cancer and to take samples from any areas inside the abdomen where the cancer may have spread. Ideally, all the areas of cancer are removed at the time of surgery, but this is not always possible.
The surgical treatment is usually followed by chemotherapy. There are a combination of chemotherapeutic agents, which are used for the treatment of ovarian cancer, but the commonest is carbo platin and taxol. This is usually given on a three weekly basis for six cycles in total. The debate about which patients benefit most from which types of chemotherapy can often be quite complex and would be a discussion outside the scope of this summary.
Most patients with ovarian cancer will be carefully followed-up. They should see their doctor every three months for the first two years and some of those patients will benefit from having a blood test on a regular basis to look at the CA125 level. If the cancer recurs then the majority of patients would be suitable to receive a second type of chemotherapy, but this would depend on the individual circumstances.
Hereditary Ovarian Cancer
The majority of cases of ovarian cancer happen by chance, but up to 20 per cent will be inherited. Mutations in at least nine genes can cause an increased risk of ovarian cancer. The Wellington Hospital work with Genetic Counsellors to help support patients if this is an inherited form of cancer. Click here for more information