Currently, women’s cancers constitute the majority of oncologic diseases that are encountered most frequently. Specialists state that regular screening and early diagnosis are essential in both protection and recovery from these disorders through effective treatment.
While lung, prostate and breast cancers are the first ones to come to mind when the word “cancer” is mentioned, women’s cancers are also among prominent cancer types. The most common gynecologic cancers are uterine, ovarian and cervical cancers. These are followed by vaginal and vulvar cancers. While some cases of cancer manifest themselves early, some are not noticed until the very last moment. Therefore, specialists state that regular screening has major significance for early diagnosis. As with all other types of cancer, women with a family history that involves one of these cancers have to take extra care to undergo screening regularly. In this article, specialists who work in the gynecology and obstetrics departments of Acıbadem Healthcare Group facilities share with us explanatory information on women’s cancers and point out the measures that can be taken against these. The points women absolutely need to know are explained by Professor C. Gürkan Zorlu of Acıbadem Taksim Hospital in regard to uterine cancer, Professor M. Faruk Köse of Acıbadem University Atakent Hospital in regard to ovarian cancer, and Professor Bülent Özçelik of Acıbadem Kayseri Hospital in regard to vaginal and vulvar cancers.
The treatment of uterine cancer, which usually develops in women between the ages of 50 and 60, varies in accordance with the stage of the disease and the general health condition of the patient.
Uterine cancer occurs in the tissue that comprises the inner layer of the uterus, referred to as the endometrium. This type of cancer, which is encountered frequently in developed countries, can be treated when diagnosed early. While the factor that triggers cell changes which lead to uterine cancer are not yet very clear, this disease, which usually develops in women between the ages of 50 and 60, can be seen in those with a family history of the disorder. The most significant symptom of the disease is vaginal bleeding. Therefore, it is essential to consult a doctor in cases of unexpected bleeding that may occur before or after menopause, regardless of the severity. Advanced cases are accompanied by vaginal discharge, palpable masses and severe pain in the lower back and the groin. The disease is diagnosed via a sample acquired from the uterine mucosa. While it is possible for cervical cancer to be detected and prevented beforehand through screening, there are no screening procedures that can indicate endometrial cancer. Professor C. Gürkan Zorlu, a gynecologist/obstetrician at Acıbadem Taksim Hospital, states that the uterus can only be examined through ultrasound and early diagnosis is only possible when there are suspicious myomas or similar formations.
COMPATIBILITY BETWEEN THE PATIENT AND THE DOCTOR IS IMPORTANT
The treatment of endometrial cancer is planned in accordance with the stage of the disease, general health condition of the patient and whether the patient wants to have a child or not. Treatment involves surgery, chemotherapy, radiotherapy, hormone therapy or a combination of some or all of these. Surgery is helpful in both staging of the disease and removal of the cancerous tissue.
Some types of women’s cancers can be treated without harming fertility. While there is no standard method for protection of fertility in uterine cancer, it is possible to preserve the ability to have children in ovarian and cervical cancers. When the ovarian cancer is limited to a single ovary and there is no metastasis, surgical operations are performed without harming the other ovary and the uterus. After the patient has a child, her other ovary and uterus can be removed as well. Protecting fertility in cervical cancer cases is much easier. When the disease is diagnosed at an early stage, only the cervix is removed and the surgical procedure is performed without harm to the uterus and the ovaries.TREATMENT DOES NOT PREVENT HAVING CHILDREN
Professor C. Gürkan Zorlu explains the prominent factors that affect treatment of uterine cancer as follows:WHAT ARE THE FACTORS THAT AFFECT TREATMENT?
· In case the patient has not yet given birth and still wishes to have a child, and if the tumor is at a very early stage and in its initial state with only local progress, it is essential to apply a fertility-preserving treatment that will keep the uterus intact. This should be followed by an accelerated process of conception and surgery right after the birth of a child. The surgical treatment options for such patients are laparoscopic, robotic and open surgery.
· It is preferred for other patients to undergo direct uterus removal surgery.
Minimally invasive, laparoscopic or robotic operations, which are all carried out with small incisions, have a high rate of success. When the disease spreads to the cervix, vagina or vulva or when there is deep myometrial invasion, radiotherapy is used. In cases where the cancer is at an advanced stage and there is recurrence, chemotherapy comes to the fore as a treatment option. After the condition fully turns into cancer, it becomes necessary to perform surgery directly. This can be followed by administration of radiotherapy, depending on certain criteria such as the extent to which the tumor has spread and the aggressiveness of the condition. In some cases where the disease is at a very early stage and the patient wishes to have a child, the tumor is eliminated locally. Professor Zorlu states that this is a decision which needs to be made after being discussed by the patient and the doctor, and says, “Since the disease the patient is fighting against is cancer, it is essential for all question marks in the mind of the patient to be eliminated”.
In ovarian cancer, of which the possibility of detection is low since it does not show any symptoms in the early stage, the success rate of the first surgical operation determines the lifespan of the patient.
Ovarian cancer, which ranks second among the most common gynecologic cancers, is also among diseases with a high mortality rate. Generally encountered in women between the ages of 50 and 70, the disease is classified in accordance with the type of cell in which it develops. Since it does not show any symptoms at the early stage, it is difficult to diagnose. The first symptoms start to appear when the disease has already spread to the surrounding organs. Professor M. Faruk Köse, who is the director of the Gynecology and Obstetrics Department at Acıbadem University Atakent Hospital, states the following: “Ovarian cancer among the most problematic women’s cancers. The disease can only be diagnosed at an advanced stage in three out of every four women and the success rate of treatment for these patients is much lower than those of other cancer patients.”
SURGERY IS THE GOLDEN STANDARD ON TREATMENT!
Ovarian cancer is treated via surgery. If all cancers that constitute the tumor can be eliminated completely during the first operation, the average life expectancy for 10 years rises to 60%. When a part of tumor smaller than 1 cm is left behind, the rate drops down to 30%. If the tumor part left behind has a size larger than 1 cm, there is no life expectancy for 10 years. Therefore, the first operation is vitally important. A study, which deems successful surgeries to be ones in which no tumor parts larger than 1 cm are left, indicates that Belgium has the highest rate of success (63%) among European countries. This means that in Belgium, the tumor size is reduced to less than 1 cm in six out of every ten patients. The success rate in England, Canada and Spain is 10%, which means that surgery on nine out of every ten women is unsuccessful. Professor Köse states that this rate is 64% in Turkey and says that the golden standard in treatment of ovarian cancer is surgery, followed by chemotherapy.
Each year, 500.000 women all over the world develop cervical cancer, a disease categorized among preventable disorders. The screening programs that are applied in developed countries make it possible for the disease to be detected at early stages.CERVICAL CANCER
As another gynecologic disease, cervical cancer is among disorders that are preventable. Prevention requires regular medical examinations, as well as a Pap smear test every three years or both a Pap smear test and an HPV DNA test every five years. There is also a vaccine developed against HPV, which was determined to be a virus that causes the disease. This vaccine is included in the general vaccine programs of countries such as USA, Italy, England, Canada, Spain, Australia and New Zealand.
Each year, 500.000 women all over the world are diagnosed with cervical cancer, a disease that develops in the lower part of the vagina, referred to as the “cervix”. The good news is that the screening programs in developed countries has decreased the rate of incidence and mortality ratio of the disease. The reason behind cervical cancer is deemed to be HPV infection. Associate Professor Ahmet Cantuğ Çalışkan, a gynecologist/obstetrician at Acıbadem Eskişehir Hospital, states that cervical cancer may not show any symptoms at the early stage and says, “In advanced stages, symptoms such as foul smelling bleeding, bloody vaginal discharge after sexual intercourse, painful and long menstrual periods, difficulty and a burning sensation while urinating, bloody urine, constipation, pain in the lower back and groin, weakness, bone pain and weight loss can appear. The golden standard in diagnosis is the Pap smear test, which involves evaluation of a sample taken from cervical tissue.
The decision on whether biopsy is required is taken according to the results from this test. The diagnosis is followed by application of methods such as pelvic examination, cystoscopy (imaging of the bladder and the urethra) and proctoscopy (detailed examination of the rectum with a device)”.
METASTASIS IS POSSIBLE
It is essential for the diseases to be staged before treatment. Many patients undergo surgery and radiotherapy at the same time. Associate Professor Çalışkan states that in cases where the tumor is limited to one area, the area itself can be completely removed or treated with local radiotherapy. Those who undergo radiotherapy usually receive chemotherapy as well. This boosts the effectiveness of radiotherapy because it is possible for cervical cancer to metastasize to surrounding tissues such as the ones in the uterus, vagina and vulva. It can also metastasize to distant organs through lymphatic spreading. When detected at an early stage, this disease, which has a 30% recurrence rate, can be treated via organ-preserving surgery on patients who wish to have children.
VAGINAL AND VULVAR CANCERS
The symptoms of vaginal and vulvar cancers, which mostly appear as a form of skin cancer, are itching, skin changes and ulcers.
Vaginal and vulvar cancers, which are also among gynecologic cancers, are less common than other diseases. Tumors in the vaginal opening and the outer lips (), which are collectively referred to as the external genital area, usually appear in the form of skin cancers. Professor Bülent Özçelik, a gynecologist/obstetrician at Acıbadem Kayseri Hospital points out that young patients should watch out for HPV by saying, “It is possible to say that HPV is a factor in development of these cancers. While the virus is not the only factor to blame, it is responsible for approximately 40% of vaginal and vulvar cancer cases”.
Apart from HPV, conditions in which the immune system is suppressed, precursor lesions and smoking are also among the causes of vaginal and vulvar cancers. The first stages of this disease, of which the development is not associated with any genetic factors, do not involve many symptoms. Advanced stages, however, are accompanied with itching in the vulva area, changes on the skin, vaginal bleeding that is not related to menstruation, bleeding after sexual intercourse and palpable masses due to lymph nodes that expand in the inguinal area.
“HPV has a role in development of vaginal and vulvar cancers. While the virus is not the only factor to blame, it is responsible for approximately 40% of vaginal and vulvar cancer cases. It is important for women not to neglect consultation in cases of long lasting itching in the vulva, particularly in the labia majora.”
NON-HEALING ULCERS ARE AMONG THE SYMPTOMS
It is also possible for vaginal and vulvar cancers to spread lymphatically. The first areas to which these spread are the groin and lymph nodes. Patients generally tend to consult a doctor due to bleeding ulcers on the skin of their genital areas. These can be preceded by itching. The itching results in non-healing ulcers; the said ulcers grow in time and turn into lesions. Professor Özçelik states that some cases are diagnosed late in spite of visible ulcers on the outer areas of the body and continues as follows: “Once the disease leads to results that are easily visible, its potential for progressing becomes very high. For example, it may be many years before an itchy lesion appears but once this lesion develops, it advances quickly because tumors have growth indices, which means that they expand gradually.”
WHEN TO GET VACCINATED
HPV, which is known to cause cervical cancer, appears in 15 different types. Types 16 and 18 are the ones that lead to cancer most frequently. In fact, it is claimed that type 18 is responsible for 70% of all cervical cancer cases. There are three different types of vaccines developed against this type of cancer. While the two-valent vaccine protects women against type 16 and 18 only, the nine-valent vaccine, which is expected to be used in Turkey soon, raises the rate of protection to 95%. It is possible for HPV vaccines to be administered between the ages of 9 and 25; however, the ideal ages for getting the vaccine are considered to be 11 and 12.
Vaginal and vulvar cancers are diagnosed via biopsy. This involves pathological examination of a sample that includes both lesion tissue and healthy tissue. While the treatment type is chosen in accordance with the biopsy results, the first option is usually surgery. The cancerous area is removed through an operation. However, it is possible for some patients to not be eligible for surgery. In such cases, radiotherapy becomes an alternative. On the other hand, radiotherapy can also be problematic if the cancerous area is curved and physically irregular. When the radiation dose fails to be applied evenly due to difficulties arising from the anatomy, the risk of problem occurrence in the bladder and intestines increases and this, in turn, decreases patient satisfaction. Chemotherapy is mostly chosen after radiotherapy and in recurrence cases.
IS IT POSSIBLE TO BE PROTECTED AGAINST THESE CANCERS?
Each of these gynecologic cancers emerge due to different risk factors. However, it is possible for women to protect themselves from these. Specialists recommend the following for protection against gynecologic cancers:
· The avoidable risks for uterine cancer are claimed to be obesity, diabetes, not having given birth, unopposed estrogen use and use of progesterone for less than 12 days during hormone replacement therapy. In other words, physical exercise, using birth control pills for contraception and giving birth multiple times are factors that decrease risk.
· Protection from cervical cancer, on the other hand, requires women to protect themselves from HPV, avoid smoking and long-term use of birth control pills, as well as undergoing regular Pap smear tests each year.