Download Gynaecological Cancer Incidence 2011

Gynaecological Cancer
Update for GPs
R D Clayton MD MRCOG
Consultant Gynae Oncologist
Gynaecological Cancer Incidence 2011
Gynaecological Cancer mortality 2010

Urgent Gynaecological Cancer Referral
NICE Guidelines
Refer 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 Referral
Refer 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 2
CA125 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 CANCER
Key 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 Med
Volume 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 CANCER
Key Developments
OV05 study 2010
Do not retreat on the basis of a raised
CA125 level
OVARIAN CANCER
Key Developments
•Bevacizumab (VEGF inhibitor) in
addition to carbotaxol
•Role of intraperitoneal chemotherapy –
being tested in PETROC trial
20.0
all uterus
body of uterus
uterus unspecified
15.0
10.0
5.0
Year of diagnosis
2007
2005
2003
2001
1999
1997
1995
1993
1991
1989
1987
1985
1983
1981
1979
1977
0.0
1975
Rate per 100,000 population
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 Adenocarcinoma
Pre-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)
18
16
females
14
12
10
8
6
4
2
Year of diagnosis
2005
2002
1999
1996
1993
1990
1987
1984
1981
1978
0
1975
Rate per 100,000 population
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
Management
Stage IB or IIA disease
No difference between
• Radical Hysterectomy
or
• 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
Rick Clayton 07796267881
Group Secretary 01612482026
(Lesley)
[email protected]
Tony Smith: Urogynae/prolapse