Gynaecological Cancer-Chapter 32:

Q 32. 1 What is cancer (malignancy)?

Living organisms (all animals and plants) are made of cells. The simplest organisms consist of just a single cell. Each cell has a central control, the nucleus surrounded by cytoplasm (Fig. 21.2).

The nucleus contains the genes, which are the biological blueprints that control the structure and function of the organism. The genes are the chromosomes – each human cell has twenty-three pairs. Each chromosome is composed of DNA (Deoxyribose nucleic acid) and the DNA is a string of nucleotides.

There are four nucleotides (A, C, G and T). The genetic code is a long string of these nucleotides grouped in threes e.g. ACG, TTT, CAG etc. The analysis of the human genetic coding is reaching completion. It has been suggested that the full code would require 40 large volumes using a standard print size.

The human body has billions of cells (Q2.1). Most cells have a limited life-span and need to be replaced. Cells are capable of duplicating themselves. Before birth and through childhood our bodies grow mainly through increase in cell numbers. The body’s cells are dividing throughout life.

The red blood cells, for example, only survive for 120 days – about one per cent of the circulating red cells are therefore replaced each day. Little is currently known about how the cells are replaced in such an orderly and precise fashion.

Fundamental to the process is the doubling of the chromosomes (mitosis) during cell replication so that each new cell has an exact copy of the chromosomes laid down in the original egg at the time of fertilisation. There are natural mechanisms that speed up the process if there has been an excessive amount of cell loss: for example, following blood loss the process of red blood cell replacement is temporarily increased.

Millions of cell divisions and replications occur daily in the body and it is astounding that the process occurs so perfectly most of the time – every cell division requires replication of the 40 volumes of genetic coding. On rare occasions there is some defect in a division and a rogue (mutant), potentially malignant cell arises.

The immune system seems to recognise such occurrences and is generally capable of removing the abnormal cells before they have an opportunity to proliferate. Rarely, there is a failure of the mechanism and a potentially malignant cell survives, replicates and cancer is the result. The four more common female cancers have their origins in the ovaries, body of the uterus, cervix of the uterus and breast, and they strike at the heart of femininity and sexuality.

Q 32. 2 What is meant by cancer staging?

Cancer staging is an agreed and defined classification of the spread of the disease determined around the time of the initial diagnosis. Stage I disease usually indicates that the tumour is confined to the organ of origin when surgical removal of the tumour or organ is likely to be associated with a good prognosis. Stage IV disease usually indicates that the tumour has spread widely and the prognosis is less favourable.
Q 32. 1 What is cancer (malignancy)?

Q 32. 2 What is meant by cancer staging?

Q 32. 3 How common is cancer?

Q 32. 4 How common are womens’ cancers?

Q 32. 5 What causes cancer?

Q 32. 6 Is cancer a hereditary condition?

Q 32. 7 How can gynaecological cancer present?

Q 32. 8 How can we reduce the risks of the womens’ cancers?

Reducing the Risks of Womens’ Cancers.

Q 32. 9 What are screening tests?

Q 32. 10 What are the reactions to a diagnosis of cancer?

Q 32. 11 Is there a place for counselling when cancer is diagnosed?

Q 32. 12 Can personality alter the prognosis?

Q 32. 13 Is the incidence of deaths from the female cancers changing?

Q 32. 14 Is there a place for a holistic approach to cancer?

Cancer of the Cervix.

Q 32. 15 How common is cervical cancer?

Q 32. 16 What causes cervical cancer?

Q 32. 17 How long an interval should there be between cervical screening (smear) tests?

Q 32. 18 Is there any evidence that cervical screening can reduce the incidence of cervical cancer?

Q 32. 19 Will pre-malignant changes of the cervix invariably lead to cancer?

Endometrial Cancer (Cancer of the Uterus).

Q 32. 20 What causes cancer of the endometrium?

Q 32. 21 Are there screening tests for endometrial cancer?

Q 32. 22 How does endometrial cancer present?

Cancer of the Ovary.

Q 32. 23 How does cancer of the ovary present?

Q 32. 24 How common is ovarian cancer?

Q 32. 25 What are tumour markers?

Q 32. 26 Can we screen for ovarian cancer?

Q 32. 27 What is the relationship between infertility and ovarian cancer?

Q 32. 28 Can treatment of infertility increase the risk of ovarian cancer?

Q 32. 29 What is the relationship between oral contraception and cancer?

Q 32. 30 Can ovarian cancer be prevented?

Q 32. 31 I use talcum power. Could this increase my risk of developing ovarian cancer?

The Treatment of Womens’ Cancers.

Q 32. 32 Can we predict the course of a cancer?

Q 32. 33 What treatment options are available for gynaecological cancer?

Cancer of the Vulva, Vagina and Fallopian Tube

Q 32. 34 How common are malignant conditions of the vulva, vagina and Fallopian tubes?

Breast Cancer.

Q 32. 35 What are the advantages of screening for breast cancer?

Q 32. 36 How often should breast screening be carried out?

Q 32. 37 Are there any problems having a mammogram?

Q 32. 38 Should I check myself for breast lumps?

Q 32. 39 One of my family developed cancer of the breast. Am I at increased risk?

Q 32. 40 We have a family tendency towards developing breast / ovarian cancer. Are there any genetic tests to find out if I am at increased risk?

Q 32. 41 What happens if a mammogram shows an abnormality?

Q 32. 42 What are the advantages and disadvantages of tamoxifen in the management of breast cancer?

Q 32. 43 What is the relationship between breast cancer and the pill?

Web sites and Support Groups

Q 32. 44 Are there any support groups?

Q 32. 45 Could I have some useful Web sites?

Women’s Health – Home Page

Q 32. 3 How common is cancer?

Internationally, it has been estimated that one in four people will develop cancer during their life and one in five will die as a result. One in three British people will develop cancer. Whilst children can develop some malignancies such as leukaemia, cancer becomes increasingly common as we age.

Table shows the increase in the incidence of cancer associated deaths in relation to women’s cancers. More than 70% of cancers first appear after the age of 65 years. In the USA, there are 2.3 million deaths annually.

The commonest cause of death is heart disease (732,000 deaths – 32%) and cancer is the second most common cause (534,000 – 23.4%). Figure 32.1 shows the incidence of new cancer cases according to site of origin and the number of deaths in the USA for 1997 estimated by the National Cancer Institute. The cost for all healthcare in the USA in 1990 was $585 billion and 6% of this was for cancer.

Q 32. 4 How common are womens’ cancers?

The incidence of new womens’ cancers in the United States in 1997 are indicated in Figure 32.2.
In the United States the combined incidence rates of the three main gynaecological cancers (uterine cervix, body of the uterus and ovary) is 43.6 per 100,000 women whereas the incidence of breast cancer is 109.5 per 100,000 women.

Table 32. 1 Incidence and survival of female cancers in the UK (1984)
% of cancer registrations New Cases/yr 5 year survival UK deaths /year % of cancer deaths
Breast 19 24,471 62% 15,245 20
Cervix 4 4,567 58% 2,234 3
Ovary 4 5,160 28% 4345 6
Endometrial 3 3,741 70% 1,050 1.6

Q 32. 5 What causes cancer?

We know that there are certain risk factors for cancer although exactly how they work is not known. We do not know why some individuals or families seem more prone to cancer although this is presumed genetic (their chromosomes are more susceptible).

In some cases it may be that mitosis has been abnormal and in others the immune system fails. Some infections may be associated with subsequent malignant change.

We now know that specific strains of the human papilloma (wart) virus can be linked to pre-malignant and malignant changes in the cervix. Sexual activity is almost invariably a factor with cancer of the cervix (neck of the womb); the younger sexual activity commences and the greater the number of partners, the higher the risk.

Hormones may alter the chance of cancer developing. Pregnancy seems to reduce the incidence of breast cancer and ovarian cancer. Hormone replacement therapy decreases the overall chance of cancer although there is a small (1.5%) increase risk of breast cancer if a woman starts the HRT at the age of 50 and continues to take it for 10 years (Q27.15). The incidence of cancer rises with age (Figure 32.3).

This is possibly a reflection of the number of times that cells have been replicated from the time of conception or that the immune system has become less effective in removing the abnormal cells.

As life-expectancy increases, the apparent incidence of cancer increases. Many women, who would have died relatively young from childhood illnesses, complications of childbirth or diseases such as tuberculosis just a century ago, now survive to an age where cancer is more likely to occur. Carcinogens are chemicals that increase the risk of malignant change. The most publicised carcinogens are in tobacco and these increase the risk of lung cancer.

We understand that infection covers a multitude of illnesses ranging from a common cold, through malaria, tuberculosis and AIDS. Similarly, cancer covers a multitude of conditions that have different causations and they respond differently to treatment. A review of the causation of women’s cancers provides an illustration (Cervix – Q32.16; Endometrium Q32.20; Ovary – Q 32.28 and Q10.8 breast – Q 27.14).

Q 32. 6 Is cancer a hereditary condition?

One person in three will develop cancer so that even if one or two family members have developed cancer, it does not necessarily mean that other family members are more at risk. There are, however, some families with an even higher incidence and extra vigilance would be appropriate. Perhaps five to ten per cent of cancers are associated with faulty genes that run in families (Q32.39/40;).

Q 32. 7 How can gynaecological cancer present?

Irregular vaginal bleeding may be the first sign of cancer of the cervix or lining of the uterus and, therefore, recurrent bleeding between periods requires medical assessment.

The first symptoms of cervical cancer include post-coital bleeding (bleeding after sexual intercourse) and blood stained vaginal discharge. The average age of presentation of cervical cancer is 45 and for endometrial cancer it is 55. Ovarian cancer may present with enlargement of the abdomen or abdominal pain.

Vulval cancer may present as a swelling or an ulcer on the vulval skin. It must be emphasised that most patients presenting with any of these symptoms will not prove to have cancer. Persistence of symptoms indicates the need for increased vigilance. It is for the doctor to assess from the story and examination findings, which investigations, if any, are required.

Q 32. 8 How can we reduce the risks of the womens’ cancers?

Questions relating to prevention or early diagnosis of the ‘female’ cancers require the fullest discussion. Cancer of the genital organs or breast is the greatest concern, if not fear, of many patients attending their gynaecologist. Initially patients may worry that their presenting symptoms indicate that they already have cancer.

The possible treatments for gynaecological problems usually include the administration of hormones and there can be anxiety that these may increase the risk of cancer developing. The best form of treatment is prevention. Screening programmes are targeted at those most at risk of developing a disease with the objective of early diagnosis before the disease becomes too advanced for curative treatment.

Pre-malignant changes of the cervix begin several years before invasive disease. Screening is designed to pick up the pre-malignant areas so that they can be destroyed before cancer occurs. Pre-malignant changes of the cervix do not cause symptoms. Cancer of the endometrium similarly passes through a pre-malignant phase (hyperplasia with severe atypia) before cancer develops. A 42 year old lady presented with bleeding between her periods. Hysteroscopy with D & C (Q24.12) were performed.

The histopathology (Q23.11) showed endometrial cancer. Hysterectomy was performed and the histopathology showed residual hyperplasia only – the tissue that had become malignant had been removed by the curettage. The prognosis for this lady is excellent.

Endometrial carcinoma is more common in those who have had relatively high oestrogen levels particularly if the endometrium has little protection from progesterone. Anovulation (menstrual cycles where no egg is released) is characterised by low progesterone levels.

Obese women are more prone to high oestrogen levels and anovulation is one cause of heavy periods. Pre-malignant and malignant changes of the endometrium are very uncommon before the age of forty years. Endometrial sampling, usually by curettage, should be considered if periods are heavy in a lady over forty (Q24.12).

Irregular bleeding between periods (intermenstrual bleeding) may be a symptom of endometrial cancer and is another important indication for sampling the endometrium in the same age group and in women in their later thirties. Bleeding after themenopause, which is called postmenopausal bleeding, could be due to an endometrial cancer.

After themenopause, the endometrial thickness should be 5 mm or less on ultrasound examination. Endometrial sampling is no longer mandatory in the investigation of postmenopausal bleeding provided ultrasound is reassuring. Ovarian cancer is relatively silent so that the majority of ovarian cancers are diagnosed relatively late.. Unlike the cervix and endometrium, the ovaries have no surface that is amenable to sampling.

Ultrasound and tumour markers are under evaluation for early identification of ovarian cancer. If the disease could be identified early, the chance of successful treatment would be greatly enhanced.

In common with the ovaries, the breasts do not have a surface that can be sampled for identification of pre-malignant or malignant changes. You can examine your breasts for the presence of small lumps.

Mammography and ultrasound of the breasts provide screening to identify early disease and thus improve the chance of cure. Some genes have been identified that are associated with increased risk for cancer of the breast and ovaries (Q32.40).

Q 32. 9 What are screening tests?

The objective of screening is to detect evidence of increased risk of disease development or to pick up disease at an early stage when the chance of successful treatment is optimised. Screening may include clinical examination by your doctor, blood tests, x-ray (e.g. mammography), ultrasound (e.g. ovaries, uterus, breasts), and cervical smears.

A. The effectiveness of a screening test must be judged on several criteria:-
B. The condition sought should be an important health risk.

C. The disease should have a well understood natural history (course).
D. The disease being screened should have an effective treatment when found early.
E. The test should be inexpensive so that the majority of those at risk can have the test.
F. The false negative rate should be low (high specificity) – the disease should not be missed.
G. The false positive rate should be low (high sensitivity) – few patients should be given unnecessary anxiety.
H. The test should be acceptable to the population.
I. Screening should be repeated at intervals depending on the natural history of the disease.
J. The risks of the test should be low.

An evaluation of screening tests for breast cancer has been applied to these criteria in Q32.35 The majority of cancers can be successfully treated if they are caught early.

In an ideal world, screening tests would be 100% successful with no false positive results causing unnecessary anxiety. Sadly, no screening test is perfect. Screening has undoubtedly reduced the risks but there is still room for improvement.

The majority of blood screening tests have a cut-off limit as there is rarely a test where the chemical being measured is not present to some degree in healthy people.

The ability of a blood screening test to diagnose a disease process (F – specificity) and its sensitivity (G) will often depend on the cut-off level (Figure 32.4). If the cut-off level is arbitrarily decreased specificity will be increased but sensitivity will fall leading to unnecessary anxiety for some.

The reverse would apply if the cut-off level is increased – the test would miss the disease more often but there would be less unnecessarily worried people.

Q 32. 10 What are the emotional reactions to a diagnosis of cancer?

Very bad news leads to a number of ‘shock’ reactions. A diagnosis of cancer is likely to result in initial numbness and a feeling of unreality. There may be anger. Some go into denial and others may start to blame themselves and at times those who have been caring for them. Fear of the disease and treatment are likely to follow.

There may be bereavement with feeling of loss of an organ if hysterectomy (hysterectomy) for example is required and perhaps grief for the potential loss of valuable years. Family and friends are also likely to go through this emotional turmoil.

Q 32. 11 Is there a place for counselling when cancer is diagnosed?

When cancer is diagnosed it is a most traumatic experience and there is usually need for the patient and her family to discuss their emotions.. Many hospitals have counsellors trained to provide support at this difficult time.

The general practitioner has an important role to play in supervising the situation when the patient is at home. Often the general practitioner will know the family well, almost as a family friend. Specialist doctors are best placed to advise on treatment.

Q 32. 12 Can personality alter the prognosis?

A study was carried out in 1982 by a psychologist at King’s College Hospital. Those with a fighting spirit lived twice as long as those who had a negative outlook.

Q 32. 13 Is the incidence of deaths from the female cancers changing?

There is evidence that the number of women dying from cancer in the under 65s has fallen in developed countries over the last 20 years. It is difficult to be certain why this has happened as there are likely to be a number of confounding factors.

Screening for cancer and pre-malignancy and improvements in the treatment of cancer are thought to have played a significant part. Figure 32.5 shows the fall in the mortality rates in the USA (Data from The National Cancer Institute – Cancer Mortality Rates from 1973 to 1994 – age under 65 in the USA).

Q 32. 14 Is there a place for an holistic approach to cancer?

The treatment of cancer is developing rapidly and the success of orthodox medicine is beyond dispute. The ‘holistic’ approach to treatment is a current ‘buzz’ word often used by those without medical qualification who wish to advertise there own brand of treatment. Doctors are highly trained to understand disease processes.

We learn a logical approach to diagnosis and the application of appropriate treatments. The importance of treating each patient as an individual person is emphasised throughout medical school and postgraduate training.

Some patients may feel the need for ‘complementary’ medicine. In my view this should never be recommended without exhausting conventional medical treatment. Disease processes such as cancer may run an unpredictable course and success stories could have occurred by chance rather than as a result of an unproven treatment.

Q 32. 15 How common is cervical cancer?

Cervical cancer is the second most common cancer in women after breast cancer. It has been estimated that 500,000 cases are diagnosed annually in the world and 80% of these are in the developing countries.

Q 32. 16 What causes cervical cancer?

The relationship between cervical cancer and sexual activity was first noted more that 150 years ago. Since then it has been assumed that sexually transmitted infection may be the underlying mechanism.

Many sexually transmitted infections have been suggested and linked to the disease. Perhaps the greatest difficulty has been that those who have acquired one sexually transmitted disease have been at risk of acquiring others.

A variety of possible organisms have been implicated including Chlamydia trachomatis and herpes simplex. Only in the last twenty years have studies of cervical cancer demonstrated that at least 99.8% are associated with the human papillomavirus (HPV). There are many ‘types’ of HPV with HPV type 16 accounting for 50%, HPV 18 for 12%, HPV 45 for 8% and HPV 31 for 5%. Acquisition of HPV does not necessarily mean that pre-malignancy or malignancy of the cervix will occur.

Experts believe that 20% of women will acquire HPV at some time in their lives but the virus is removed from the body in the majority. A number of factors determine whether the HPV will not be eliminated and whether pre-malignancy and then malignancy will occur. Some people have a genetic predisposition to malignancy.

Smoking is thought to reduce the efficiency of the immune system increasing the risks. The socially disadvantaged are most at risk of cervical cancer. The condom method of contraception provides protection against cervical cancer.

Women who have used oral contraception are twice as likely to have high grade pre-malignant conditions of the cervix compared to those who never used it probably because they have been less likely to have used a barrier method of contraception.
References:

Case-control study of oestrogen replacement therapy and risk of cervical cancer (1997-1774).

Q 32. 17 How long an interval should there be between cervical screening (smear) tests?

Current evidence would suggest that, if an initial screen is negative, the next screen should be three years later. If repeat smears are negative a five year screening programme would seem reasonable.

The World Health Organization has recommended that in countries where resources are limited, every woman should have screening at least once in her life. The Institute of Cytology and Preventative Oncology in India suggest that the optimum time for once in a life-time screening would be at age 45 years. References: Relation between the incidence of invasive cervical cancer and the screening interval: is a five year interval too long? (1996-2091d)

Q 32. 18 Is there any evidence that cervical screening can reduce the incidence of cervical cancer?

Epidemiologists in Sweden have recently reviewed the literature on screening results.

They found seventeen cancer registries large enough and existing long enough to evaluate the effects of screening. Incidence rates of cervical cancer fell by more than 25% in eleven of the registries ranging from 27% in Norway to 77% in Finland. Following the initial fall in incidence with the introduction of screening, the incidence of cervical cancer has remained stable over the last 20 years in developed countries.

Figure 21.6 shows the falling rates in the incidence of cervical cancer and deaths from the disease in the UK from 1955 – 1985. This fall has been associated with an increase in diagnosis and treatment of pre-malignancy.

Q 32. 19 Will pre-malignant changes of the cervix invariably lead to cancer?

The majority of women with pre-malignant conditions of the cervix will not develop cancer. One study in Norway suggested that four out of five women with CIN III would not progress into frank malignancy although others studies suggest that this is an underestimate. The mean (a statistical term approximately indicating the average) time delay from pre-malignancy to malignancy is around 16 years.

Q 32. 20 What causes cancer of the endometrium?

In contrast to cancer of the cervix, there is a higher incidence in more affluent society and those with few children. Being overweight increases the chance of endometrial cancer.

Women with PCOS are more at increased risk of endometrial cancer partly as these women tend to be overweight and also because they may have anovulatory cycles, which are characterised by oestrogen unopposed by progesterone. Endometrial cancer is the ninth commonest cancer in women and the third commonest gynaecological cancer.

The incidence of endometrial cancer tends to peak between the ages of 50 and 65 years. Tamoxifen, used in the treatment of breast cancer can increase the risk of endometrial cancer; some recommend annual endometrial sampling.

The relationship between endometrial cancer and oestrogens is discussed elsewhere (Q27.14; 27.15; 32.43). Modern HRT, which would always include progestogen if the uterus is present, is associated with an overall decreased incidence of endometrial cancer (Q27.19).

Q 32. 21 Are there screening tests for endometrial cancer?

There are currently no specific screening tests routinely undertaken for endometrial cancer. Early in the disease process, however, irregular bleeding occurs between periods before the menopause or there is otherwise postmenopausal bleeding. Fortunately symptoms occur early so that the prognosis is relatively good provided these symptoms are investigated without undue delay.

Heavy periods after the age of forty or intermenstrual bleeding are indications for evaluating the endometrium – usually by hysteroscopy and D & C (Q24.12). Pre-malignant changes occur that are described as varying degrees of hyperplasia. When there is severe atypical hyperplasia, there is a 50% risk of cancer developing; hysterectomy (hysterectomy) is clearly advisable.

Q 32. 1 What is cancer (malignancy)?

Q 32. 2 What is meant by cancer staging?

Q 32. 3 How common is cancer?

Q 32. 4 How common are womens’ cancers?

Q 32. 5 What causes cancer?

Q 32. 6 Is cancer a hereditary condition?

Q 32. 7 How can gynaecological cancer present?

Q 32. 8 How can we reduce the risks of the womens’ cancers?

Reducing the Risks of Womens’ Cancers.

Q 32. 9 What are screening tests?

Q 32. 10 What are the reactions to a diagnosis of cancer?

Q 32. 11 Is there a place for counselling when cancer is diagnosed?

Q 32. 12 Can personality alter the prognosis?

Q 32. 13 Is the incidence of deaths from the female cancers changing?

Q 32. 14 Is there a place for a holistic approach to cancer?

Cancer of the Cervix.

Q 32. 15 How common is cervical cancer?

Q 32. 16 What causes cervical cancer?

Q 32. 17 How long an interval should there be between cervical screening (smear) tests?

Q 32. 18 Is there any evidence that cervical screening can reduce the incidence of cervical cancer?

Q 32. 19 Will pre-malignant changes of the cervix invariably lead to cancer?

Endometrial Cancer (Cancer of the Uterus).

Q 32. 20 What causes cancer of the endometrium?

Q 32. 21 Are there screening tests for endometrial cancer?

Q 32. 22 How does endometrial cancer present?

Cancer of the Ovary.

Q 32. 23 How does cancer of the ovary present?

Q 32. 24 How common is ovarian cancer?

Q 32. 25 What are tumour markers?

Q 32. 26 Can we screen for ovarian cancer?

Q 32. 27 What is the relationship between infertility and ovarian cancer?

Q 32. 28 Can treatment of infertility increase the risk of ovarian cancer?

Q 32. 29 What is the relationship between oral contraception and cancer?

Q 32. 30 Can ovarian cancer be prevented?

Q 32. 31 I use talcum power. Could this increase my risk of developing ovarian cancer?

The Treatment of Womens’ Cancers.

Q 32. 32 Can we predict the course of a cancer?

Q 32. 33 What treatment options are available for gynaecological cancer?

Cancer of the Vulva, Vagina and Fallopian Tube

Q 32. 34 How common are malignant conditions of the vulva, vagina and Fallopian tubes?

Breast Cancer.

Q 32. 35 What are the advantages of screening for breast cancer?

Q 32. 36 How often should breast screening be carried out?

Q 32. 37 Are there any problems having a mammogram?

Q 32. 38 Should I check myself for breast lumps?

Q 32. 39 One of my family developed cancer of the breast. Am I at increased risk?

Q 32. 40 We have a family tendency towards developing breast / ovarian cancer. Are there any genetic tests to find out if I am at increased risk?

Q 32. 41 What happens if a mammogram shows an abnormality?

Q 32. 42 What are the advantages and disadvantages of tamoxifen in the management of breast cancer?

Q 32. 43 What is the relationship between breast cancer and the pill?

Web sites and Support Groups

Q 32. 44 Are there any support groups?

Q 32. 45 Could I have some useful Web sites?

Women’s Health – Home Page

Q 32. 22 How does endometrial cancer present?

Bleeding after the menopause or irregular bleeds in the forties and fifties requires careful assessment by a gynaecologist. Before themenopause, hysteroscopy and endometrial biopsy or curettage are required (Q24.12). Transvaginal ultrasound can be of value after the menopause. If the endometrium is no more than 5mm thick and appears normal, further investigation may not be required.

Q 32. 23 How does cancer of the ovary present?

The ovaries are to be found deep inside the pelvis on either side of the uterus. Cancer of the ovary is usually silent until it becomes advanced. At the time of diagnosis, 75% of ovarian cancers have advanced to Stage III or IV (Q32.2).

The commonest presentation is enlargement of the abdomen either due to the tumour or the large amount of fluid associated with it (ascites). The two more common reasons for the abdomen to become distended, however, is laxity of the abdominal wall muscles or the bowel becoming too full.

Q 32. 24 How common is ovarian cancer?

Ovarian cancer is the fifth commonest cancer in women. In1988 there were 5,830 new cases reported in the United Kingdom. The majority of ovarian cancer is found in women aged more than 45 years.

Women who have had children or taken the combined oral contraceptive pill are afforded a degree of protection. Ovarian cancer was responsible for 4,360 deaths in the UK in 1992, which was more than the total for the other gynaecological cancers.

Q 32. 25 What are tumour markers?

A tumour marker is a chemical that is produced by tumour cells and can be measured in the blood or other body fluids. It may be used to detect the presence of a tumour and subsequently to monitor the progress of the disease and response to treatment.

An ideal tumour marker (which remains to be discovered) would have a cut-off point where there would be no false positives or negatives (Q32.9). Recent technological advances have allowed the evaluation of a large number of chemicals as potential tumour markers.

In gynaecology there are three tumour markers of proven value – Ca125, HCG and alpha-fetoprotein. Ca125 is a tumour marker that is associated with ovarian cancer. Some ovarian cancers may not result in an increase in Ca125 levels.

There are several reasons that limit the value of currently available tumour markers. Most tumour-associated markers are also produced by healthy tissues so that there is an overlap of levels between those with a tumour and healthy people. Ca125, the ovarian cancer marker, increases in 20% of healthy women during their periods and in 50% of women during pregnancy.

It is non-specific and may be increased in some endometrial or bowel cancers. Raised levels may also be found in association with benign conditions of the ovary, pelvic inflammation and endometriosis.

The pre-placental tissue of pregnancy (trophoblast) produces human chorionic gonadotrophic hormone (HCG) and its presence is the first evidence of pregnancy. Occasionally (about one pregnancy in a thousand) in the UK, the trophoblast becomes an innocent tumour (hydatidiform mole). Rarely, this may become malignant – choriocarcinoma; HCG levels are useful to monitor patients who have had a hydatidiform mole.

Disgerminomas, (rare ovarian tumours in young women) may result in high levels of HCG. Alpha-fetoprotein (AFP) is produced by foetal tissues. When there is an open spina bifida the levels of AFP in the amniotic fluid and mother’s blood rise.

This was the first useful test for detecting spina bifida during pregnancy but has become superseded by ultrasound examination of the fetus. AFP levels may be increased in association with some rare “germ cell” tumours of the ovaries.

References:

Risk of diagnosis of ovarian cancer after raised serum CA 125 concentration: A prospective cohort study (1996-1594)

Tumour markers and their role in the monitoring and prognosis of epithelial ovarian cancer (1996-1671).

Q 32. 26 Can we screen for ovarian cancer?

As ovarian cancer usually first makes itself apparent at a relatively late stage, the concept of screening to detect ovarian cancer at a relatively early stage is particularly attractive. There are two screening tests currently available for ovarian cancer – ultrasound and a blood test for Ca125.

Some ovarian cancers, but not all, are associated with an increase of a chemical in the blood called Ca-125. If a blood test shows a raised level of Ca125 there is an increased risk that there are cancer cells in the ovaries. The Ca125 level is raised (<35ku/l) in 80% of all ovarian cancers but in only 50% of patients with cancer confined to one ovary (Stage I0).

False positive results of Ca125 can occur with endometriosis, benign cysts, pelvic inflammation and cancers from other sites. Other tumour markers are being evaluated. One new tumour marker, OVX1, has shown elevated levels when the Ca125 was giving a false negative result.

A fifty-three year old lady was known to have a fibroid uterus the size of a four month pregnancy. She arranged an ovarian screening Ca125 test at another hospital and the result was elevated.

They recommended surgery but as we had previously known about the fibroid we managed to avoid an operation for her. Six years later on she remains well and the fibroid has become smaller as she has gone through her menopause.

An ultrasound scan (Q4.9) may show a picture suggestive of cancer. The vaginal probe allows the picture to be seen from very close to the ovaries. Neither ultrasound nor the Ca125 tests can absolutely confirm or refute the possibility of cancer. It has been suggested that for every 10 women with a positive result, only one will actually have cancer.

The limit of resolution for ultrasound is about 1 cm. For one malignant cell to multiply to reach the size of 1 cm requires 10 billion cell divisions.

There is only another 1000 fold increase required to reach a weight of 1 Kg. Ovarian cancer screening is at an early stage of development so that there are as yet no large studies to confirm the potential benefits.

In 1989, a committee in the UK assessed the situation and concluded that it was of unproven benefit and could not be recommended as a routine.

An American committee came to a similar conclusion in 1994. Screening, therefore, remains an area for research. Some women have a family history of ovarian cancer. For women with no family history of ovarian cancer the cumulative risk of ovarian cancer by the age of 70 is about 1% and if there is one close relative with the disease the risk is about 3%. With two close relatives the cumulative risk may lie between 15 and 30%.

For women in the UK in this high risk group screening is available in the National Ovarian Cancer Registry Screening Programme, which is organised from Addenbrooke’s Hospital in Cambridge. There is a relationship between ovarian cancer and breast cancer.

Women with two affected close relatives with breast cancer before the age of 40 or one with ovarian cancer and one with breast cancer diagnosed before the age of 50 are also eligible. A genetic screen on a blood sample can identify women at increased risk.

(Q32.40) Several hospitals have research interests evaluating screening the ovaries. If you feel that you may be at high risk they may be happy to screen you regularly. Screening is usually conducted annually.

References:

Cost effectiveness of shortening screening interval or extending age range of NHS breast screening programme: Computer simulation study (1998-2185)

Q 32. 27 What is the relationship between infertility and ovarian cancer?

Women who have a history of infertility seem to have a slightly higher risk of developing ovarian cancer.

References:

Infertility, fertility drugs, and invasive ovarian cancer: A case-control study (1997-1713)

Q 32. 28 Can treatment of infertility increase the risk of ovarian cancer?

A study of nearly 4,000 women investigated for infertility in Seattle, USA between 1974 and 1985 was reported in 1994. Eleven women had developed ovarian cancer or borderline malignancy, whereas statistically four would have been expected. Nine of the affected women had taken clomiphene ( a fertility drug Q10.7).

Five of these had taken the clomiphene for at least 12 months. Treatment with clomiphene for less than 12 months was not associated with increased risk of ovarian cancer.

Following this report The Committee on Safety of Medicines in the UK, whilst accepting that further studies were required, recommended that clomiphene should not normally be prescribed for more than six cycles. Women could take it for longer provided that they were made aware of the risks and gave informed consent.

There is evidence that the majority of women would accept a modest increase in their lifetime risk of ovarian cancer that might be associated with their fertility treatment.

Several groups have reported their data on this issue. Some provide reassurance that there is no strong association between fertility drugs and subsequent of ovarian cancer. Others support the contention that there may be an increased risk. The latest research is leaning towards reassurance.

Q 32. 30 Can ovarian cancer be prevented?

Removing the ovaries (prophylactic oophorectomy) can prevent ovarian cancer. There are two clinical situations currently where the gynaecologist may need to address the question of removing the ovaries.

The first is at the time of elective pelvic surgery, hysterectomy (Q24.19) being the obvious example. The second is when there is a strong family history of ovarian malignancy.

At one time removing ovaries was frequently performed as part of the management of breast cancer. These days, oestrogen antagonists such as tamoxifen appear to be as effective (Q32.42).

Q 32. 1 What is cancer (malignancy)?

Q 32. 2 What is meant by cancer staging?

Q 32. 3 How common is cancer?

Q 32. 4 How common are womens’ cancers?

Q 32. 5 What causes cancer?

Q 32. 6 Is cancer a hereditary condition?

Q 32. 7 How can gynaecological cancer present?

Q 32. 8 How can we reduce the risks of the womens’ cancers?

Reducing the Risks of Womens’ Cancers.

Q 32. 9 What are screening tests?

Q 32. 10 What are the reactions to a diagnosis of cancer?

Q 32. 11 Is there a place for counselling when cancer is diagnosed?

Q 32. 12 Can personality alter the prognosis?

Q 32. 13 Is the incidence of deaths from the female cancers changing?

Q 32. 14 Is there a place for a holistic approach to cancer?

Cancer of the Cervix.

Q 32. 15 How common is cervical cancer?

Q 32. 16 What causes cervical cancer?

Q 32. 17 How long an interval should there be between cervical screening (smear) tests?

Q 32. 18 Is there any evidence that cervical screening can reduce the incidence of cervical cancer?

Q 32. 19 Will pre-malignant changes of the cervix invariably lead to cancer?

Endometrial Cancer (Cancer of the Uterus).

Q 32. 20 What causes cancer of the endometrium?

Q 32. 21 Are there screening tests for endometrial cancer?

Q 32. 22 How does endometrial cancer present?

Cancer of the Ovary.

Q 32. 23 How does cancer of the ovary present?

Q 32. 24 How common is ovarian cancer?

Q 32. 25 What are tumour markers?

Q 32. 26 Can we screen for ovarian cancer?

Q 32. 27 What is the relationship between infertility and ovarian cancer?

Q 32. 28 Can treatment of infertility increase the risk of ovarian cancer?

Q 32. 29 What is the relationship between oral contraception and cancer?

Q 32. 30 Can ovarian cancer be prevented?

Q 32. 31 I use talcum power. Could this increase my risk of developing ovarian cancer?

The Treatment of Womens’ Cancers.

Q 32. 32 Can we predict the course of a cancer?

Q 32. 33 What treatment options are available for gynaecological cancer?

Cancer of the Vulva, Vagina and Fallopian Tube

Q 32. 34 How common are malignant conditions of the vulva, vagina and Fallopian tubes?

Breast Cancer.

Q 32. 35 What are the advantages of screening for breast cancer?

Q 32. 36 How often should breast screening be carried out?

Q 32. 37 Are there any problems having a mammogram?

Q 32. 38 Should I check myself for breast lumps?

Q 32. 39 One of my family developed cancer of the breast. Am I at increased risk?

Q 32. 40 We have a family tendency towards developing breast / ovarian cancer. Are there any genetic tests to find out if I am at increased risk?

Q 32. 41 What happens if a mammogram shows an abnormality?

Q 32. 42 What are the advantages and disadvantages of tamoxifen in the management of breast cancer?

Q 32. 43 What is the relationship between breast cancer and the pill?

Web sites and Support Groups

Q 32. 44 Are there any support groups?

Q 32. 45 Could I have some useful Web sites?

Women’s Health – Home Page

Q 32. 31 What is the relationship between talc and ovarian cancer?

A number of studies have suggested that the use of talcum powder applied to the genital area may increase the risk of ovarian cancer but the credibility of this association has been questioned. The debate continues with one recent report concluding that there is a significant association and that formal public health warnings are warranted.

References:

A meta-analytical approach xamining the potential relationship between talc exposure and ovarian cancer. (1995 – 2827)

Perineal talc exposure and subsequent epithelial ovarian cancer: A case- control study. (1999 – 2828)

Genital talc exposure and risk of ovarian cancer. (1999 – 2829)

Q 32. 32 Can we predict the course of a cancer?

Within a short time of diagnosis, doctors will be able to determine whether the tumour shows any sign of spread. The earlier the diagnosis is made, the less likelihood there is of spread and the greater the chance of cure. A cancer is usually staged at the time of initial surgery when the degree of spread is evaluated. Some cancers, such as skin cancers show themselves early. Others, such as ovarian cancer are more silent so that diagnosis is likely to be relatively late in the disease process.

There are databases from which we can determine the number of patients likely to survive five or ten years based on staging but there is wide variation between patients. The 5-year survival for stage 1 ovarian cancer is 98% whereas the 5-year survival for stage 3 and 4 is less than 30%.The pathologist who examines cancer tissue can provide some indication of how virulent the tumour looks: A well differentiated tumour looks closer to normal than a poorly differentiated tumour.

Again, there are statistics telling us the percentage of patients likely to be cured or survive over a year or five years but these cannot accurately tell us how well an individual may fare. From my own earliest experience I learned about the unpredictability of cancer. My family was advised six years before I was born, that an aunt was unlikely to survive more than a few months.

She lived to see the arrival of my two younger cousins and they are six years junior to me. A lady in her late sixties had abdominal symptoms and proved to have an advanced ovarian cancer. Many years earlier she underwent hysterectomy (hysteectomy) and her ovaries had been conserved. At initial laparotomy, the tumour was too advanced for removal. The tumour responded rapidly to chemotherapy and most of the tumour was removed at a second laparotomy some months later. She enjoyed a further four years of active life.

The course and outcome of cancer will vary from patient to patient. Some cancers, for example, respond to treatment such as chemotherapy (the use of drugs that destroy malignant cells) and others do not.There are claims that 50% of cancers can be cured and that modern treatment significantly increases the quality and duration of life for many of the other 50%.
References:

Conservative surgery for stage I ovarian carcinoma in women of childbearing age (1997-1881)

Q 32. 33 What treatment options are available for gynaecological cancer?

There are four main treatment options to try to remove or destroy cancer. Surgery aims to remove the growth completely or otherwise as much as is safely possible (debulking). Radiation destroys cells and its effect is more marked on some malignant tissues than healthy tissues. Similarly, the objective of chemotherapy is to use drugs that kill malignant cells selectively. Some tumours are inhibited by hormone therapy. Cancer specialists (oncologists) may recommend additional treatment after surgery to improve cure rates even if there is a high chance that surgery has completely removed the tumour.

A: Surgery Gynaecological cancer (ovary, uterus, cervix and vulva) surgery is increasingly undertaken by those with a special interest in the subject. Similarly, surgery on the breast is usually undertaken by a general surgeon with a corresponding special interest. The surgeon is always balancing the potential benefits of the operation and the risk of complications (Q4.21). Some patients are anxious about surgery for cancer as they fear that the operation can accelerate the disease. There is no evidence that this happens.

There are times when the cancer is found to be more advanced at surgery than expected and the outcome is less favourable.Surgical removal of the tumour is the primary treatment for cancer of the endometrium, ovary and breast. In the early stages of cervical cancer surgery is the first line of treatment particularly in younger healthy women. Extensive surgery for cancer is termed ‘radical’. A Wertheim’s hysterectomy, employed for the surgical treatment of early cancer of the cervix, involves removal of lymph glands and tissue on either side of the uterus and it is, therefore, more extensive than the usual abdominal hysterectomy.

The pendulum swung initially towards radical surgery but recently back towards less extensive surgery. With early cervical cancer, some specialists are now removing the lymph glands laparoscopically and removing the cervix whilst leaving the uterus and fertility intact. Similarly, removal of the whole breast (mastectomy) is no longer as frequently employed. Removal of the lump (lumpectomy) and dissection of lymph glands has become more popular. Ovarian cancer is an indication for surgical removal of all of the tumour if possible or otherwise as much as possible.

There is still some debate as to the advantages of radical surgery for ovarian cancer as complication rates are increased with more aggressive surgery.Beyond the age when fertility is an issue, hysterectomy with removal of both ovaries is usually the objective.

In a young woman with tumour confined to one ovary, removal of that ovary alone may be all that is required.In the majority of cases the surgical objectives for ovarian tumours are straightforward but there are times when there are confounding factors. For example, the patient may be keen to conserve at least one ovary and her uterus but the surgeon may be concerned about leaving undiagnosed malignancy.

A frozen section (a representative sample removed at operation and examined microscopically during the operation providing a provisional answer within a few minutes) is only of value in a small number of cases. A 32 year old lady attended for her initial pregnancy assessment at 12 weeks. This was her second pregnancy.

In her first pregnancy her AFP (Q32.25) level was low, at that time indicating further investigation (amniocentesis – obtaining a fluid sample from around the baby) to exclude Down’s syndrome. That test proved negative and she went on to deliver a healthy baby. At the first examination in the second pregnancy the uterus seemed to be larger than would have been expected for her dates. The two more likely causes would have been twins or that the pregnancy was more advanced than the dates indicated. An ultrasound examination was requested and this demonstrated just one baby with a size consistent with the dates.The right ovary was enlarged and our radiologist was suspicious of ovarian malignancy.

A blood test was sent for tumour markers and the AFP was extremely high. Now the most likely diagnosis was a yolk sac tumour, which is an extremely rare occurrence. Advice was taken from several experts. At 16 weeks into the pregnancy a laparotomy was performed. The tumour was confined to the right ovary which was removed. It proved to be a malignant teratoma which is even more rare than a yolk sac tumour.

The pregnancy continued and serial scans and AFP tests were reassuring. At 38 weeks an elective Caesarean section was performed. A healthy baby was delivered and the opportunity taken to confirm that there was no evidence of tumour. Mother and child have done well and 11 years later there remains no sign of the original tumour returning.

This tumour has almost certainly been cured by surgery alone. Radical surgery, chemotherapy or radiotherapy were never required. Malignant teratomas are highly malignant but in recent years the prognosis has improved as they tend to be sensitive to chemotherapy if required. This case is interesting for a number of reasons not least being that it was detected early because of clinical examination simply to assess early pregnancy.

B: Radiotherapy. Some malignancies, such as cervical cancer may be particularly sensitive to radiotherapy. There are a variety of radiation sources and the treatment requires careful planning by doctors and physicists specialising in this mode of treatment.

Traditionally, special applicators were introduced into the uterus and vagina and radium was inserted into these applicators. They were kept in place for up to 48 hours and during this time the patient was kept still to prevent movement of the applicators. There have been significant advances and radiotherapy is faster, less painful and associated with less complications than even a few years ago.

The applicators are introduced under general anaesthetic and the radioactive sources are after loaded to protect staff. The modern sources provide stronger radioactive output so that treatment has been reduced to less than 30 minutes. Pelvic radiotherapy can cause troublesome diarrhoea.

C: Chemotherapy. Chemotherapy employs cytotoxic (toxic to cells) drugs that interfere with the cell division of malignant cells. There is a fine balance between the maximum dose of these drugs that can be safely given and the risk of damaging healthy tissues. Cytotoxic drugs affect cells that are dividing rapidly. Common side-effects, therefore, include anaemia, reduced resistance to infection, ulcers, and hair loss. Some cytotoxic agents are given by mouth although most are given though a vein (intravenously).

They may be given over the course of a few days and are often repeated at three or four week intervals. Treatment of ovarian cancer has improved the short and medium term survival. New chemotherapeutic agents are being developed and evaluated by clinical trials. Chemotherapy is particularly effective against ovarian germ cell tumours.

D: Hormones. Some cancers, particularly cancer of the endometrium and breast are hormone sensitive. There is evidence that breast cancer outcome is more favourable for some women who are given tamoxifen, which is an anti-oestrogen. Cancer of the uterus seems to be inhibited by progestogens and it is our policy to commence medroxyprogesterone if the diagnosis is suspected at curettage; it is continued for one year.
References:

A new treatment for endometrial cancer with gonadotrophin releasing-hormone analogue (1991-142)

Q 32. 34 How common are malignant conditions of the vulva, vagina and Fallopian tubes?

Cancer arising from these sites is uncommon. They occur mainly after the menopause and they are best treated by a gynaecologist with special interest in cancer. There is a weak relationship between lichen sclerosus (Q31.5) and vulval cancer but the vast majority of women with lichen sclerosus do not develop cancer. Surgery is the primary method of treatment. Cancer of the vulva is treated by radical vulvectomy (surgical removal of the vulva and the lymphatic glands that drain the area).

I have only seen one patient with primary cancer of the vagina. Initially, it seemed to be like an early cervical cancer except it was just below the cervix. It was successfully treated by radiotherapy. There have been three primary cancers of the Fallopian tube. One was such a rare variety that it became the first to be reported from the UK.

The latest presented as if it was arising from an ovary. The patient had undergone hysterectomy (hysterectomy) some years before and the left ovary and tube had not been removed. It would appear that this will be the third case in the world literature of carcinoma of the Fallopian tube following hysterectomy.

Q 32. 35 What are the advantages of screening for breast cancer?

The merits of a screening test are listed in Q32.9. With reference to Q32.8, breast cancer is an important health risk (A). There are 24,000 new cases and 15,000 deaths reported annually in the UK. Breast cancer is the commonest cancer in women in the UK (B). One women in twelve (7.5%) will develop breast cancer at some time in her life.

The majority of breast cancers are found in women over the age of 55 years. We know a lot about the natural history of the disease (C). When the tumour is limited to a duct or measures less than 1 cm, spread to the lymph glands is least likely to have occurred. Screening aims to detect this early stage of disease. The five year survival for stage 1 breast cancer (less than 2 cm) with appropriate treatment is 84% whereas it falls to 18% for stage 4 disease (D). The UK screening programme (mammography) costs £37 million per year.

An evaluation in 1986 found that the cost per quality-adjusted life year (a year of good health quality) achieved by screening compared favourably to other approved and established screening programmes (E). Mammography has high specificity (low false negatives – (F) and sensitivity (low false positives – G). In the three years from 1992, 4,729,003 women aged 50-65 were offered mammography – 3,582,332 (75.8%) accepted (H).

Breast biopsies were required for 24,651 women (0.69% of those having mammograms). Breast cancer was identified 19,792 (0.55%). Cancer of 1 cm or less was found in 5,785 (0.16%). References: The value of ultrasound scanning in breast disease. Review Sonographic evaluation of benign and malignant breast lesions (1996-2101)

Q 32. 36 How often should breast screening be carried out (Q 32. 9 – I)?

The ideal interval has yet to be established. The UK was one of the first to offer national breast screening with mammography. All women aged 50 – 64 are offered screening at three year intervals. The Department of Health is currently assessing the potential of extending the upper limit of screening to the age of 69. Most European programmes screen at two year intervals. A British trial looking at this interval is due to report in 1998.

The Cancer Research Campaign is evaluating the possible benefits of mammography starting at age 40. The breasts in younger women are usually too dense for interpretation of x-ray mammography. Sonography (ultrasound examination of the breast) is accurate but the investigation requires considerable expertise and is time-consuming. References: Serum concentrations of cancer antigen 125, placental alkaline phosphatase, cancer-associated serum antigen and free beta human chorionic gonadotrophin as prognostic markers for epithelial ovarian cancer (1997-1880)

Q 32. 37 Are there any problems having a mammogram (Q32. 9 – J)?

Compression of the breast during mammography can be painful but the discomfort is just for a short time. Mammography involves radiation. Current evidence suggests that, at most, mammography could be the cause of cancer in one woman for every two million women screened. Whereas cervical screening is designed to pick up cervical disease before it becomes malignant, breast cancer screening is designed to pick up the disease when it has already become active although hopefully early enough to provide curative treatment.

Q 32. 38 Should I check myself for breast lumps?

The majority of doctors would advocate self-checking on a regular basis. More than 90% of breast cancers are found by the woman herself. If any change is noted, early assessment by the doctor is to be highly recommended. The breast tissue becomes more nodular (lumpy) before each period so that it is best to undertake examination after a period.

The breasts are composed of lobes of glandular tissue that can be felt between the thumb and the fingers by gentle squeezing – this is therefore not the method to examine the breast for lumps or thickening. The hand should be closed and flat with the fingers being gently but firmly pressed in and moved to feel for swellings. Imagine each breast in four quarters and systematically check each of these areas. Other changes such as discharge or bleeding from the nipple should also be reported to your general practitioner.

Q 32. 39 One of my family developed cancer of the breast. Am I at increased risk?

The significance of breast cancer in the family on the chance of another family member being affected is disputed. Early studies found the risk ratio (Q33.27) for developing breast cancer to be 1.9 if the mother has had cancer of the breast and 2.3 if the disease had affected a sister.

There is virtually no increased risk for more distant relatives. However, a meta-analysis (Q33.23) could find no evidence that there as an increased risk of breast cancer even if a close relative had the disease. A meta-analysis of 51 studies, reported in The Lancet in 1997 evaluating the relationship between HRT and breast cancer demonstrated no increased risk for those whose mothers or sisters have had breast cancer to those with no family history.

Q 32. 40 We seem to have a family tendency towards developing breast / ovarian cancer.

Are there any genetic tests to find out if I am at increased risk? For some women with a very strong history of breast or ovarian cancer it may be appropriate to test for the high penetrance breast cancer susceptibility gene BRCA1 (Breast Cancer 1). This gene is located on chromosome 17. More intensive and frequent screening of those at increased genetic risk would appear to be appropriate.

It is wise for the implications to be carefully addressed by a counsellor before the test is performed. It may be that we shall be able to provide a degree of reassurance, for some women at least, when there is a history of breast cancer in the family. Other genes are currently being evaluated in several research centres.

Q 32. 41 What happens if a mammogram shows an abnormality?

Nine out of ten women found to have an abnormality on mammography do not have cancer. If an abnormality is detected on the mammogram a sample of tissue is taken by the breast specialist often under local anaesthetic. A pathologist will then examine this biopsy microscopically to provide the definitive diagnosis. The emotive issues around breast screening, the need for quick evaluation and access to specialist consultation and treatment are being increasingly recognised by many units.

Q 32. 42 What are the advantages and disadvantages of tamoxifen in the management of breast cancer?

Evidence from the International Breast Cancer Trialists Collaborative Group have found that any woman with hormone sensitive breast cancer would benefit from tamoxifen regardless of her age or menopausal status.

Tamoxifen has been shown to protect substantially against breast cancer recurrence and death. These conclusions were derived from a meta-analysis (Q33.23) of 55 trials involving 37,000 women. In the group of women with oestrogen sensitive tumours or those with unknown oestrogen sensitivity, there was a 47 % reduction in recurrence rate over ten years following five years of tamoxifen treatment. The survival rate was improved by 11 % over ten years. Tamoxifen was associated with a slight increase in the incidence of endometrial cancer.

Q 32. 43 What is the relationship between breast cancer and the pill?

Breast cancer is common with more than 600,000 new cases reported internationally each year. Many studies have been undertaken to determine whether the pill might place women at increased risk of breast cancer. The results of meta-analyses (Q33.23) are reasonably reassuring with at most a marginal increase. This must be balanced against several pill benefits including reduction in the risk of ovarian and endometrial cancer, fibroids, ovarian cysts, endometriosis, benign breast disease and ectopic pregnancy. Those women found to have breast cancer whilst taking the pill are usually diagnosed at an early stage so that the prognosis is relatively good.

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Introduction To Women’s Health

Anatomy and Physiology

Diseases of Women

Diagnosis & Treatment

Children and Adolescence

Absent & Infrequent Periods

Polycystic Ovary Syndrome

Hirsutism – Excess Body Hair

Infertility Investigations

Infertility Treatments

Treatment Outcomes

Early Pregnancy Problems

Contraception – Family Planning

Mirena & Mini- Pills

Combined Pills

Pill – Practical Issues

IUCDs & Postcoital Rx

Sterilisation

Termination of Pregnancy

Gynaecological Infection

The Cervix

Disorders of the Vagina

Pelvic Pain & Painful Periods

Heavy Periods – Hysterectomy

Premenstrual Syndrome

The Menopause

HRT Risks & Benefits

HRT Preparations

Bladder Symptoms

Prolapse of the Uterus & Bladder

Disorders of the Vulva

Malignancy

Medication in Gynaecology

Illustrations

About The Author

Acknowledgements

Awards

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Q 32. 44 Are there any support groups?

https://2womenshealth.com/

Q 32. 45 Could I have some useful Web sites?

Evaluation of the quality of Web sites is discussed in Q4.27. You may find that several general women’s health sites may help you (Q4.28). The following are more specialised Web sites on topics found in this chapter:

• Women’s Cancers: www.gog.org/ www.macmillan.org.uk/ www.wcn.org/ womenscancercenter.com/ Breast Cancer: www2.kumc.edu/kci/cancerlinks/breast.htm http://www.breastcancercare.org.uk/ http://www.breastcancer.org/ oncolink.upenn.edu/disease/breast/ www.thebreastclinic.com/

www.freenet.scri.fsu.edu/HealthGazette/breast.html http://cancer.gov/ www.surgery.wisc.edu/breast_info/laybreastca.html Cervical Cancer: www.cancerbacup.org.uk/info/cervix.htm http://www.thecancer.info/cervix/index.asp www.gyncancer.com/cervix.html www.nccc-online.org/ oncolink.upenn.edu/specialty/gyn_onc/cervical/ http://www.thecancer.info/cervix/index.asp

Endometrial Cancer: www.cancerbacup.org.uk/info/uterus.htm www.cancerlinksusa.com/endometrium.htm http://www.cancer.gov/cancerinfo/pdq/treatment/endometrial www.gyncancer.com/uterus.html www.ontumor.com/endometrium.htm Ovarian Cancer: www.gyncancer.com/ovarian-cancer.html www.mayohealth.org/mayo/9905/htm/ovarian.htm http://www.ovarian.org/ www.ovariancancer.org/ http://www.ovariancanada.org/