Knowing is half the battle: Gynecological cancers explained

Q&A with Dr. Richard Cardosi on What You Need to Know to Stay—or Get—Healthy

Dr. Richard Cardosi, a board-certified gynecologic oncologist and Polk County Medical Association member, provides comprehensive care for women with gynecologic malignancies and complex benign gynecologic conditions at Watson Clinic’s main office. He serves as president of Watson Clinic Foundation, looking for ways to make a difference in the community through education, research, and service. We talked with Dr. Cardosi about gynecological cancer – what it is and what can be done about it.

Central Florida Health News (CFHN): What is the most prevalent type of gynecological cancer? What are the warning signs?

Dr. Richard Cardosi: Uterine cancer is the most common gynecologic cancer. It is the fourth most common cancer among all women in America.  Patients with uterine cancer typically have abnormal uterine bleeding and are postmenopausal.

CFHN: What other types of gynecological cancers are there?

Dr. Cardosi: Cancers of the uterus, cervix, vulva, vagina, ovary, fallopian tube, primary peritoneal cancer, and gestational trophoblastic disease are all considered gynecologic malignancies.

CFHN: Should healthy women be checked periodically for gynecological cancer?

Dr. Cardosi: All women should have what’s called “Well Women” care.  This is often performed by a gynecologist, but may be obtained from a woman’s primary care physician, such as an internist or family medicine physician. This Well Woman visit is an opportune time to review reproductive health, immunizations, appropriate cancer screenings, thyroid or cholesterol screening, or to discuss hormonal therapy, tobacco cessation, or other health concerns.  These evaluations have different focuses at different times in a woman’s life.  The early detection of problems can often result in a situation that is easier to treat/manage, preventing it from becoming a serious health concern.

There is unfortunately no adequate screening test for most gynecologic cancers, although a Pap smear is an excellent screening tool for cervix cancer. Women should still be seen on a regular basis even if a Pap smear is not needed; a Pap smear is only part of the reason for a well woman visit.

CFHN: How is gynecological cancer treated?

Dr. Cardosi: This is a broad question, but surgery, chemotherapy, and radiation may all be used individually or in combination.  Surgery may be a minor procedure, as in minimally invasive robotic assisted or laparoscopic procedures, or rather radical with extensive intra-abdominal resection of disease.  Chemotherapy may be hormonal or involve the more typical cytotoxic medications that people usually think of when they hear this term.  Radiation also can range from a much directed local therapy to a more classic radiation to the whole pelvis.  Each of these modalities may be used differently for different cancers and/or at different times in the disease course.  Basically, we try to individualize therapy to be specific—not only to the patient’s disease—but also to the patient, in efforts to maximize tumor response and outcome while minimizing toxicity and maintaining quality of life as much as possible.

CFHN: Is gynecological cancer easy to cure?

Dr. Cardosi: Curability really depends on the cancer type and its extent at diagnosis.  Most early stage gynecologic cancers have high five-year survival rates, while most advanced stage cancers do not, unfortunately, fair as well.  However, some cancers still are able to be cured, even when presenting with extensive disease.  Ultimately, this all comes down to tumor biology. Occasionally even early stage cancers will not respond to our most aggressive therapies; women with widely metastatic disease occasionally may do quite well.

CFHN: What role does human papillomavirus play in gynecological cancer? Do you recommend HPV vaccinations? For what age groups?

Dr. Cardosi: HPV is involved with the development of cervical cancer, vaginal cancer, and some vulvar cancers.  This is a sexually transmitted virus that incorporates itself into the patient’s cells, possibly causing them to “transform.”  What we don’t fully understand is:

  • Why some patients get HPV, but it never develops into a problem;
  • Why other women continue having recurring HPV-related issues, but it never develops into an invasive cancer; and thirdly,
  • Why some women do develop an HPV-related cancer.

Again, it comes down to the “aggressiveness” of the HPV particle and to the immune response the patient is able to mount.  HPV vaccines are very effective and I think they should be considered by all (boys and girls) before sexual activity/HPV exposure. The immune response from the vaccine appears to be most significant in younger patients. Based on current studies, it is recommended between the ages of nine and 26.  It is important to understand, however, that these vaccines do not prevent infection with ALL HPV types. Therefore, continued routine medical care, cancer screening, and appropriate sexual behavior must continue to be emphasized.

CFHN: Are there other ways a woman can protect herself from gynecological cancer?

Dr. Cardosi: Obesity is by far the most significant risk factor for uterine cancer.  An obese woman has a tenfold increased risk of uterine cancer, so maintaining appropriate body weight is clearly quite beneficial.

I personally think obesity is the biggest issue facing medicine today—as obesity is directly related to the development of hypertension, high cholesterol, diabetes, arthritis, and heart disease. Just think of the impact on healthcare costs if we could eliminate obesity!

Having children decreases a woman’s risk of both uterine and ovarian cancer. Use of birth control pills significantly decreases the risk of both uterine cancer and ovarian cancer as well.  Breastfeeding also has been associated with decreased rates of ovarian cancer.

The risk of HPV related cancers can obviously be decreased by avoiding multiple sexual partners and following appropriate cervical cancer / Pap smear screening recommendations.  Environmental and genetic factors clearly play a role, but they are not well understood.

CFHN: What is the cause of gynecological cancer? Is the disease more prevalent than it used to be?

Dr. Cardosi: There are many theories on the cause of the different gynecologic cancers. The most popular theory regarding the development of ovarian cancer has to do with ovarian surface injury related to monthly ovulation. Data over the past few years, however, is beginning to point to the fallopian tubes as the origin of ovarian cancer.  Again, uterine cancer is obesity related and this is thought to be related to weak estrogens produced by fat cells. But not all obese women develop uterine cancer, and not everyone with uterine cancer is obese.  Clearly, we still have a lot to learn regarding the cause of gynecologic cancers.

CFHN: Once a woman has succumbed to gynecological cancer, is it there a high reoccurrence rate after successful treatment?  How can she protect herself?

Dr. Cardosi: Once a woman gets cancer, her risk of recurrence depends on many factors—type of cancer, stage/extent of disease, and success of primary treatment. There are some other outcome predictors from a molecular standpoint, but these are not something that can be influenced with today’s technology, at least not yet. These predictors are simply informative of risk and not something we can do anything about.  When tumors recur, the chance of successful management also depends on these same variables, in addition to knowing how long it has been since the patient completed her last treatment (few months vs. few years), how extensive her recurrence is and where it is located (isolated vs. widely metastatic), and her ability to tolerate second line treatments (repeat surgery, chemotherapy, radiation, etc.).  In other words, early stage uterine cancer rarely recurs, and when it does, it is often salvageable. Advanced ovarian cancer frequently recurs and is difficult to cure at that point, but often is somewhat manageable for a period of time with additional therapies.  The best course for a patient, after completing primary therapy, is to simply be compliant with follow-up recommendations and report new or changing symptoms to her doctor.

CFHN: Does gynecological cancer spread easily to other parts of the body?

Dr. Cardosi: Again, this depends on the cancer type.  Uterine cancer commonly presents with bleeding, for which patients quickly seek attention. The disease is therefore often diagnosed early, and metastatic spread is relatively uncommon.  Cervix cancer is almost universally picked up early in patients who are compliant with well woman care and Pap smear screening; however, for women who do not get Pap smears, cervix cancer may not be detected until the onset of pain, bleeding, or even kidney obstruction, which is typically a sign of advanced disease.

Ovarian cancer, on the other hand, develops on the surface of the ovary, inside a patient’s body. As those cancer cells split off, they spread to other parts of the abdominal cavity. Roughly 75 percent of women diagnosed with ovarian cancer present with stage III/IV disease; the diagnosis of a stage I ovarian cancer is almost always unforeseen.  All gynecologic cancers may spread to any part of the body via direct spread (like ovarian cancer noted above), lymphatic spread to lymph nodes, or through the blood stream to the liver, lungs, bones, brain, etc.

CFHN: Is there anything else you would like to add about current detection and treatment option?

Dr. Cardosi: It is very important for women to be sure an appropriately trained gynecologic oncologist is involved in their care if they have a gynecologic cancer or a pelvic mass or similar that might be a cancer.  Studies have shown that such involvement leads to an improved oncologic outcome.

Also, there is not a good screening test for ovarian cancer.  We have studied pelvic ultrasound and various serum tumor markers and none perform at the desired level.  These same tumor markers are often used to help triage/risk stratify a pelvic mass. They are simply not reliable.  The best approach to determine whether a mass is benign or malignant is to consult with a gynecologic oncologist, who can review the patient’s symptoms, exam, family history, ultrasound or computerized tomography (CT) scan images, and any serum tumor markers.

Lastly, minimally invasive surgery has drastically improved surgical outcomes in patients with gynecologic cancers.  Robotic assisted laparoscopic surgery allows us to do major procedures with intricate precision and less morbidity/complications. It then allows the patient to recover quicker and return to normal activity.  This technology is not for every patient or every situation, but it is becoming more prevalent. More than 70 percent of my surgeries are currently completed with this technology, which obviously has significant patient benefits.  Since these patients recover quicker with fewer complications, they require less time in the hospital and are able to return to work sooner. It therefore has the potential to decrease healthcare costs when used selectively and correctly.

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