Gynaecological CancerUpdate for GPs

R D Clayton MD MRCOG

Consultant Gynae Oncologist

Gynaecological Cancer Incidence 2011

Gynaecological Cancer mortality 2010

Urgent Gynaecological Cancer ReferralNICE GuidelinesRefer Urgently:

with clinical features suggestive of cervical cancer on examination. A smear test is not required before referral, and a previous negative result should not delay referral

not on hormone replacement therapy with postmenopausal bleeding

on hormone replacement therapy with persistent or unexplained postmenopausal bleeding after cessation of hormone replacement therapy for 6 weeks

taking tamoxifen with postmenopausal bleeding

Urgent Gynaecological Cancer ReferralRefer Urgently:

with an unexplained vulval lump or with vulval bleeding due to ulceration

Consider urgent referral for patients with persistent intermenstrual bleeding and negative pelvic examination

Refer urgently for an ultrasound scan patients: with a palpable abdominal or pelvic mass on examination that is not obviously uterine fibroids or not of gastrointestinal or urological origin.

If the scan is suggestive of cancer, an urgent referral should be made. If urgent ultrasound is not available, an urgent referral should be made

Ovary - Case History 1

65 yo woman presents with 3 month history of abdominal bloating, and pelvic pain, with symptoms suggestive of IBS. Prior to this she had been well.

Q1. What are the most important investigations

Ovary - Case History 1

Q1. What are the most important investigations?

• Ultrasound scan abdo/pelvis• CA125 measurement• Clinical examination• Bowel investigations

Ovarian Cancer:

the recognition and initial management of ovarian cancer

Full guideline April 2011

Developed for NICE by the National Collaborating Centre

for Cancer

Ovarian Cancer: Nice Guidelines

• Focuses on areas of uncertainty• GPs are often criticised for delays in

diagnosis• Relatively rare cancer (5th commonest)• Symptoms often none specific

Ovarian Cancer: Nice Guidelines

‘tests’ should be carried out in primary care if a woman (especially if 50 or over) reports having any of the following symptoms on a persistent or frequent basis;

• persistent abdominal distension• feeling full (early satiety) and/or loss of appetite• pelvic or abdominal pain.• increased urinary urgency and/or frequency.

Ovarian Cancer: Nice Guidelines• Consider carrying out ‘tests’ in primary care if a woman

reports unexplained weight loss, fatigue or changes in bowel habit.

• Advise any woman who is not suspected of having ovarian cancer to return to her GP if her symptoms become more frequent and/or persistent.

• Carry out appropriate tests for ovarian cancer in any woman of 50 or over who has experienced symptoms within the last 12 months that suggest irritable bowel

syndrome (IBS), because IBS rarely presents for the first time in women of this age.

Ovarian Cancer: Nice Guidelines

BUT WHAT TEST SHOULD WE DO?

Ovarian Cancer: Nice Guidelines

• Clinical evidence and Health economic evaluation was performed.

• Initial test should be CA125• If this is raised then perform an

ultrasound• If both are ‘positive’ refer to secondary

care (Sequential testing)

Ovarian Cancer Management

What can you tell the patient?

• Laparotomy – what this entails• Risks and additional procedures• Any Chemotherapy pre op or post op?• Types of chemotherapy

Case History 2

The previous patient comes to the surgery with her 45 year old daughter who has had 3 episodes of abdominal bloating in the last month related to food but no change in bowel habit.

Q2. Would you measure her CA125 level?

Case History 2CA125 levels – pitfalls• Not elevated in up to 50% of stage 1 ovarian

cancers• Can be raised for other reasons

• Benign ovarian cysts eg endometriosis• Fibroids• Connective tissue disorders• Heart failure/liver failure• Other malignancies eg breast or lung

Case History 2

Consequences?• Unnecessary investigations• Unnecessary interventions

Ovarian cancer

OVARIAN CANCERKey Developments

When should we operate?

How much ‘surgical effort’ should we make?

Original Article Neoadjuvant Chemotherapy or Primary Surgery in

Stage IIIC or IV Ovarian Cancer

Ignace Vergote, M.D., Ph.D., Claes G. Tropé, M.D., Ph.D., Frédéric Amant, M.D., Ph.D., Gunnar B. Kristensen, M.D., Ph.D., Tom Ehlen, M.D., Nick Johnson, M.D., René H.M. Verheijen, M.D., Ph.D., Maria E.L. van der Burg, M.D., Ph.D., Angel J.

Lacave, M.D., Pierluigi Benedetti Panici, M.D., Ph.D., Gemma G. Kenter, M.D., Ph.D., Antonio Casado, M.D., Cesar Mendiola, M.D., Ph.D., Corneel Coens, M.Sc., Leen

Verleye, M.D., Gavin C.E. Stuart, M.D., Sergio Pecorelli, M.D., Ph.D., Nick S. Reed, M.D., for the European Organization for Research and Treatment of Cancer–Gynaecological Cancer Group and the NCIC Clinical Trials Group — a Gynecologic

Cancer Intergroup Collaboration

N Engl J MedVolume 363(10):943-953

September 2, 2010

EORTC Study Overview

• Randomized trial, standard primary debulking surgery followed by chemotherapy was compared with neoadjuvant chemotherapy followed by debulking surgery in women with bulky stage IIIC or IV ovarian cancer.

• Starting treatment with chemotherapy allowed more patients to undergo optimal tumor debulking during the subsequent operation.

• However, the outcomes were the same regardless of the timing of the debulking operation.

• Primary chemotherapy is an option in the management of bulky ovarian cancer.

EORTC Study Overview

• Surgical Effort – how far should we go?

• Is Chemotherapy the important factor?

• Is ability to debulk related to the inherent tumour biology.

• Is perioperative morbidity greater with upfront debulking surgery.

OVARIAN CANCERKey Developments

OV05 study 2010

Do not retreat on the basis of a raised CA125 level

OVARIAN CANCERKey Developments

•Bevacizumab (VEGF inhibitor) in addition to carbotaxol

•Role of intraperitoneal chemotherapy – being tested in PETROC trial

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Figure 1.5: Age-standardised (European) incidence rates, uterus cancer, by sex, GB, 1975-2007

Endometrial Cancer Case History?

A 70 year old woman presents with 3 episodes of heavy post menopausal bleeding.

Q1 What are the referral options? Q2 What investigations will be

performed?

Endometrial AdenocarcinomaPre-operative Imaging

•TV USS useful as diagnostic/screening tool •One stop PMB clinic is the gold standard•MRI is the method of choice for radiological staging once diagnosis established•Best for prediction of depth of myometrial invasion and cervix involvement

Endometrial Adenocarcinoma

Management

• Consider laparoscopic approach• Role of lymph node removal uncertain (ASTEC)• Role of brachytherapy – (PORTEC 2)

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Figure 1.2: Age standardised (European) incidence rates, cervical cancer, Great Britain, 1975-2007

Cervix Cancer Aetiology

• Pre-invasive phase of CIN

• Usually due to HPV

Aetiology

Management of High grade CIN

Management of High grade CIN

What are the risks of loop excision?

Management of CIN

Cervix case history 1

A 35 year old woman consults you as she is very worried about the possibility of cervix cancer and wants to be vaccinated. She has had a loop excision for CIN 3 approx 5 years before with negative smears since

Q. What would you advise her?

Cervix case history 2

She wants to know how long the vaccine will work for and whether she will need any booster injections at a later date?

Q. What would you advise her?

Cervix case history 3

The same woman brings along her son who is aged 13 saying that she has heard it is a good idea to have him vaccinated against HPV

Q. What would you advise her?

HPV vaccination

• Cervarix for national programme changed to Gardasil

• Will routine smears be necessary in the future?• HPV vaccination for older women?• Duration of immunity?• HPV vaccination for males?

HPV vaccination

• Cervarix for national programme•

HPV triage and test of cure

HPV triage and test of cure

Cervix – Case History 4

A 22 yr old nulliparous woman presents with an abnormal appearing cervix. You are concerned there may be a cervical cancer and the patient asks you what options may be available for treatment.

Q – What would you tell her?

Cervix – Case History

•Radical Hysterectomy

•Radical Trachelectomy

•ChemoRadiotherapy

ManagementStage IB or IIA disease

No difference between

• Radical Hysterectomyor• Radiotherapy

(Landoni et al, Lancet, 1997)

Fertility sparing surgery for stage IB or IA2

• Radical Trachelectomy and laparoscopic lymphadenectomy

Conclusions

Recent major changes in management of• Ovarian• Endometrial• Cervical

ANY QUESTIONS

Any questions?

www.northwestgynaecology.co.uk

At the Alexandra Hospital

Gail Busby: Paed Gynae

Rick Clayton: Gynae Onc

Edi Edi-Osagie: Fertility

Kristina Naidoo: Hysteroscopy

Tony Smith: Urogynae/prolapseRick Clayton 07796267881Group Secretary 01612482026(Lesley)lesley@northwestgynaecology.co.uk