Gynecologic cancers & women's health.

It was only in retrospect that Rebecca Reynolds recognized something was wrong. Sure, she felt bloated and had gained a few pounds, but wasn't that just part and parcel of middle age? Sure, her stomach was a mess, with indigestion, gas, diarrhea and constipation, but she'd had such symptoms on and off throughout her life. And sure, she was tired. But she was also going 100 miles an hour planning her son's wedding; who wouldn't be tired?

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So when her gynecologist felt a mass on one of her ovaries during a routine checkup in November 2002, no one was more surprised than Ms. Reynolds, then 56. "I didn't know anything about ovarian cancer," says the Colorado Springs woman. In fact, when she had a hysterectomy in 1991 she'd insisted that her ovaries remain.

Today, after surgery to remove her ovaries and eight rounds of chemotherapy, Ms. Reynolds probably knows more about the disease than she ever wanted to.

It's knowledge she's desperate to impart to other women, both through her role as the president of the southern Colorado chapter of the National Ovarian Cancer Coalition, and as an ovarian cancer survivor. Her message: Listen to your body. "Your body really will speak to you and if you pay attention, you and your health care professional can catch these diseases early."

The Forgotten Cancers

Over 80,000 women a year are diagnosed with a gynecologic (gyn) cancer, most with one of the three main types: ovarian, endometrial and cervical. Although most are quite curable if caught early, gyn cancers still claim the lives of 26,000 women a year, often because women aren't aware of their early warning signs. (21)

"Many women do not know nearly as much about gyn cancers as they do about breast cancer," says Carolyn Y. Muller, MD, associate professor of gynecologic oncology at the University of Texas Southwestern Medical Center in Dallas. "One reason, I think, is that there is so much misinformation passed down from generation to generation. Also, there is very little time allotted in the gynecologist's office for thorough education."

Plus, she notes, "Gynecologic cancers tend to be less visible in the political arena, and so don't draw as much media coverage or education dollars from Congress."

All that may change if legislation working its way through Congress passes. Called Johanna's Law, the bill would require a nationwide public service announcement suggesting that women talk to their doctors about gynecologic cancers, and would fund grants to local and national organizations to test innovative strategies for educating women about various gynecologic cancers. (1)

"We have a lack of understanding of gynecologic cancers in this country," says James W. Orr, Jr., MD, president of the Society of Gynecologic Oncologists.

That is slowly changing. In 1999, Congress declared September national Gynecologic Cancer Awareness Month, and this year, for the first time, all 50 states have issued their own proclamations. "This year, Gynecologic Cancer Awareness Month has swept the nation," said Gynecologic Cancer Foundation Chairman Karl C. Podratz, MD, PhD. "With all 50 states proclaiming the month this year, we can be hopeful that more women will learn about gynecologic cancers and the importance of regular check-ups, and that this awareness will help save lives."

With that in mind, here's what you should know.

Ovarian Cancer: Often Overlooked

Although breast cancer affects many more women than ovarian cancer, ovarian cancer is much more deadly. Diagnosed in more than 25,580 women every year and resulting in about 16,090 deaths a year, ovarian cancer ranks fifth in cancer deaths among women and causes more deaths than any other gynecologic cancer. (2) Additionally, the risk of developing and dying from ovarian cancer is higher for Caucasian women than African-American women. (3)

"It's a very difficult disease to diagnose," agrees Thomas J. Herzog, MD, who directs the division of gynecologic oncology at Columbia University's College of Physicians and Surgeons in New York City. "The symptoms that do occur are often vague and can occur as the result of many other causes."

Since there is no reliable test to diagnose ovarian cancer (see Screening for Ovarian Cancer on page 3), health care professionals have to rely on a woman's reporting of symptoms, the feel of a woman's ovaries during an annual exam, and the not-so-great diagnostic ability of a transvaginal ultrasound.

A recent study published in the Journal of the American Medical Association found that 94 percent of women surveyed who were diagnosed with ovarian cancer had symptoms in the year prior to their diagnosis, and 67 percent had recurring symptoms. (4) The most common symptoms? Bloating, increased abdominal size, fatigue, urinary tract symptoms and pelvic or abdominal pain--all of which are symptoms common to other medical conditions.

No wonder that 70 percent of women with ovarian cancer are diagnosed in the late stages of the disease, when the chance of surviving five years is only 30 percent. Conversely, the 20 percent of women diagnosed with early-stage disease have an excellent prognosis, with over 95 percent alive five years after diagnosis. (3)

A woman's best bet, says Dr. Herzog, is to be aware of any risk factors she may have. A big one is family history. Women with certain mutations on the BRCA1 and BRCA2 genes, the so-called "breast cancer" genes, have a significantly increased risk of ovarian cancer, he notes, as do women with a family history of the disease. (6)

If you suspect you have a higher risk for ovarian cancer, says Dr. Herzog, you should see a gynecologic oncologist or a genetic counselor who can put the issue into the correct context and recommend appropriate preventive strategies if you test positive for a BRCA mutation.

Today, ovarian cancer is often viewed as a chronic disease rather than a mostly fatal one as new treatments become available. That's why Dr. Herzog and others urge women diagnosed with ovarian cancer to enroll in clinical trials. "It's through these trials that in the last 10 to 15 years we've been able to improve the five-year survival rate," he says. Women can learn about such trials at: http://www.clinicaltrials.gov and http://www.centerwatch.com.

Endometrial Cancer: Easily Diagnosed

Why do so many women who experience bleeding after menopause ignore it? If Monica B. Jones, MD, assistant professor, division of gynecologic surgery at the Mayo Clinic in Rochester, MN, knew the answer to that, she'd be a much happier doctor. And maybe have to treat fewer advanced cases of endometrial cancer.

Unlike ovarian cancer, endometrial cancer (also known as uterine cancer) cancer announces itself quite obviously with irregular bleeding or bleeding after menopause. "We'll have women come in who have been bleeding for months and they're 10 years past menopause," says Dr. Jones. "They think they just overexerted themselves."

The doctor has a message for these and other postmenopausal women: "Bleeding after menopause is abnormal all the time. It is the biggest warning that something is wrong, and women should not delay seeking care after any episode of postmenopausal bleeding, even spotting," she says. Yet on average, women wait about nine months from the time their bleeding starts before seeing a health care professional, notes Dr. Orr.

Endometrial cancer is the most common form of gynecologic cancer. Overall, an estimated 40,320 women are diagnosed with the disease and 7,090 women die from it every year. Though it's a cancer diagnosed mainly in women after menopause, endometrial cancers can and do occur in younger women. (2)

The greatest risk factor? Obesity. "We know that the more a woman weighs over her ideal body weight, the higher her risk of developing endometrial cancer," says Dr. Jones. That's because fat cells serve as a storage house for androgens, hormones that convert to estrogen which, in turn, stimulate the lining of the uterus.

You also have an increased risk of uterine and ovarian cancer if your family has a strong history of colon cancer, she says, particularly if it fits the profile of hereditary non-polyposis colon cancer, or HNPCC. If you have this syndrome in your family, you have a 40 to 60 percent chance of developing endometrial cancer.

The good news is that 70 percent of endometrial cancers can be diagnosed while the cancer is confined to the uterus, with an 85 percent cure rate, notes Dr. Jones. However, she adds, successfully curing this disease is more likely to occur when women recognize the early warning signs and seek care promptly.

Cervical Cancer: Younger Women Be Aware

Someday, cervical cancer may really be a thing of the past, as rare a disease as smallpox is now. But today, cervical cancer affects approximately 10,520 women a year, with 3,900 deaths expected this year. (2)

Nearly all cases of cervical cancer can be linked to the human papilloma virus, or HPV, a sexually transmitted virus. That's one reason cervical cancer primarily affects younger women, those between the ages of 30 and 55. However, women of all age groups should be aware of cervical cancer and talk to their health care professionals about how to prevent it. (17)

The cancer is particularly prevalent in Hispanic women, who have twice the incidence rate and 1.4 times the death rate from cervical cancer as Caucasian women. (7) It is also more prevalent in Native American women. Although the incidence among African-American women is nearly the same as that of Caucasian women, Caucasian women are more likely to have their cancers diagnosed at the earliest, most easily treatable stage (56 percent versus 47 percent). (2)

The differences in incidence and stage of diagnosis are likely due to differences in screening rates, says Dr. Muller. One large study found that 11 percent of women don't get Pap tests at all. (8) Dr. Muller and other experts suspect many in this population are less educated, are from poorer socioeconomic backgrounds and have different cultural challenges, says Dr. Muller. "They may not understand what a Pap test is, or they may have cultural objections to having the test," she says.

For instance, some Hispanic women come from cultures that strongly value a woman's ability to bear children, says Dr. Muller. So, she notes, fear of hysterectomy may keep her from getting screened or following up on suspicious Pap tests, resulting in the higher incidence and death rates.

Yet cervical cancer is nearly 100 percent preventable with regular Pap test screenings. The Pap, which screens for cellular changes in the cervix that precede the disease, is responsible for a 74 percent drop in cervical cancer deaths since its introduction 50 years ago. (9)

Unfortunately, half of all newly diagnosed women have never had a Pap test, and 10 percent haven't been screened within the past five years. (10)

In recent years, new forms of Pap tests and other new technologies have health care professionals excited about the ability to better diagnose precancerous lesions. For instance, in March 2003, the U.S. Food and Drug Administration (FDA) approved a new approach to cervical cancer screening for women 30 and older: the use of an HPV test in conjunction with the Pap test. If both are negative, says Dr. Muller, the woman may not need to have another Pap for up to three years. If the HPV is positive, she adds, even if the Pap is negative, then the woman will need additional testing.

Guidelines from the American Cancer Society recommend beginning cervical cancer screening about three years after a woman begins having intercourse, but no later than age 21. After that, women should have a regular Pap test every year or a liquid-based Pap test every two or three years.

At or after age 30, women who have had three normal test results in a row may undergo screening every two to three years, the guidelines state, while women 30 and older may want to consider HPV testing with a Pap test. Women 70 and older who have had three or more normal Pap test results and no abnormal results in the last 10 years may stop having Pap screenings. (11)

Most exciting, however, is the possibility of a vaccine that would protect women against the HPV virus in the first place, potentially eradicating cervical cancer. Results from the first major clinical trial of the vaccine found it was 100 percent effective in protecting women who had never been exposed to one type of the HPV virus. However, it won't have any effect on women already exposed, notes Dr. Muller. Instead, once approved, the vaccine will probably be recommended for young girls before sexual exposure takes place.

"Even if we vaccinated all 10-year-old girls today, you won't see any difference in the amount of abnormal Pap tests, precancerous lesions or cervical cancer, for another 40 or 50 years," says Dr. Muller. We first have to finish with the generations of women who have already been exposed to HPV."

Resources

American Cancer Society

1-800-227-2345

http://www.cancer.org

Offers many resources about diagnosing, treating and preventing a wide range of cancers, as well as support and advocacy for those with the disease.

Gynecologic Cancer Foundation

230 West Monroe, Suite 2528

Chicago, IL 60606

312-578-1439

http://www.thegcf.org

Established by the Society of Gynecologic Oncologists to ensure public awareness of gynecologic cancer prevention, early diagnosis and proper treatment.

The Women's Cancer Network

http://www.wcn.org

This interactive Web site informs women about gynecologic cancer; offers free confidential risk assessments for gynecologic cancer.

The National Cervical Cancer Public Education Campaign

http://www.cervicalcancercampaign.org

Led by the Gynecologic Cancer Foundation, the campaign seeks to improve cervical cancer screening and early detection by increasing awareness about the disease.

The National Cervical Cancer Coalition

2625 Alcatraz Avenue, Suite 282

Berkeley, CA 94705

1-800-685-5531

http://www.nccc-online.org

Provides a range of information about cervical cancer for women with, or at risk for, the disease.

National Ovarian Cancer Coalition

1-888-682-7426

http://www.ovarian.org

Offers resources about ovarian cancer and support and advocacy to women and their families at risk for the disease.

RELATED ARTICLE: Screening for Ovarian Cancer

Unlike cervical, breast, colon and prostate cancer, all of which have highly effective screening tests available, ovarian cancer remains incredibly difficult to catch at an early stage, when it is easiest to treat.

The most commonly used test, the CA-125 test, detects levels of a protein on the surface of many cancer cells. "The test is generally unreliable for primary screening in the general population and thus is FDA-approved only for testing for recurrent cancer," says Thomas J. Herzog, MD, who directs the division of gynecologic oncology at Columbia University's College of Physicians and Surgeons in New York City. Plus, only half of patients with early-stage ovarian cancer have an elevated CA-125 level.

Recently, however, researchers have been evaluating new methods that use the fledgling science of proteomics (the study of the proteins that govern every biological process in the body) to identify ovarian cancer in its earliest--and most treatable--stages.

One approach was developed by scientists at the National Cancer Institute and the U.S. Food and Drug Administration (FDA) in conjunction with Correlogic Systems, Inc., a pharmaceutical/biotechnology company, in Bethesda, MD. It uses protein fingerprinting to potentially identify Stage 1 ovarian cancer from just a few drops of blood in a 30-minute test. A recently published research paper reported that of 68 cancer specimens this test correctly identified the majority of cancer specimens as cancerous, without identifying any non-cancer specimens as cancerous. (13) Another test using a similar concept is much closer to hitting the market. Called OvaCheck, it was developed by Correlogic Systems alone and is currently undergoing large clinical trials.