Gynaecological Cancer - PowerPoint Presentation

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Gynaecological CancerUpdate for GPs

R D Clayton MD MRCOG

Consultant Gynae OncologistSlide2

Gynaecological Cancer Incidence 2011Slide3

Gynaecological Cancer mortality 2010Slide4

Urgent Gynaecological Cancer ReferralNICE GuidelinesRefer 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 Slide5

Urgent Gynaecological Cancer ReferralRefer Urgently:with an unexplained vulval lump or with vulval bleeding due to ulcerationConsider urgent referral for patients with persistent intermenstrual bleeding and negative pelvic examinationRefer 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 madeSlide6

Ovary - Case History 165 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 investigationsSlide7

Ovary - Case History 1Q1. What are the most important investigations?Ultrasound scan abdo/pelvisCA125 measurementClinical examinationBowel investigationsSlide8

Ovarian Cancer: the recognition and initial management of ovarian cancerFull guideline April 2011Developed for NICE by the National Collaborating Centre for CancerSlide9

Ovarian Cancer: Nice Guidelines Focuses on areas of uncertaintyGPs are often criticised for delays in diagnosisRelatively rare cancer (5th commonest)Symptoms often none specificSlide10

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.Slide11

Ovarian Cancer: Nice GuidelinesConsider 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.Slide12

Ovarian Cancer: Nice Guidelines BUT WHAT TEST SHOULD WE DO?Slide13

Ovarian Cancer: Nice Guidelines Clinical evidence and Health economic evaluation was performed.Initial test should be CA125If this is raised then perform an ultrasoundIf both are ‘positive’ refer to secondary care (Sequential testing)Slide14

Ovarian Cancer ManagementWhat can you tell the patient?Laparotomy – what this entailsRisks and additional proceduresAny Chemotherapy pre op or post op?Types of chemotherapySlide15

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?Slide16

Case History 2CA125 levels – pitfallsNot elevated in up to 50% of stage 1 ovarian cancersCan be raised for other reasonsBenign ovarian cysts eg endometriosisFibroidsConnective tissue disordersHeart failure/liver failureOther malignancies eg breast or lungSlide17

Case History 2 Consequences?Unnecessary investigationsUnnecessary interventionsSlide18

Ovarian cancerSlide19
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OVARIAN CANCERKey DevelopmentsWhen should we operate?How much ‘surgical effort’ should we make?Slide21

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, 2010Slide22

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.Slide23

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.Slide24

OVARIAN CANCERKey DevelopmentsOV05 study 2010Do not retreat on the basis of a raised CA125 levelSlide25

OVARIAN CANCERKey DevelopmentsBevacizumab (VEGF inhibitor) in addition to carbotaxolRole of intraperitoneal chemotherapy – being tested in PETROC trialSlide26
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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?Slide28

Endometrial AdenocarcinomaPre-operative ImagingTV USS useful as diagnostic/screening tool One stop PMB clinic is the gold standardMRI is the method of choice for radiological staging once diagnosis establishedBest for prediction of depth of myometrial invasion and cervix involvementSlide29

Endometrial AdenocarcinomaManagement Consider laparoscopic approach Role of lymph node removal uncertain (ASTEC) Role of brachytherapy – (PORTEC 2)Slide30
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Cervix Cancer AetiologyPre-invasive phase of CINUsually due to HPVSlide32

AetiologySlide33

Management of High grade CINSlide34

Management of High grade CINWhat are the risks of loop excision?Slide35

Management of CINSlide36

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 sinceQ. What would you advise her?Slide37

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?Slide38

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 HPVQ. What would you advise her?Slide39

HPV vaccinationCervarix for national programme changed to GardasilWill routine smears be necessary in the future?HPV vaccination for older women?Duration of immunity?HPV vaccination for males? Slide40

HPV vaccinationCervarix for national programme Slide41

HPV triage and test of cureSlide42

HPV triage and test of cureSlide43

Cervix – Case History 4A 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? Slide44

Cervix – Case HistoryRadical HysterectomyRadical TrachelectomyChemoRadiotherapySlide45

ManagementStage IB or IIA diseaseNo difference betweenRadical HysterectomyorRadiotherapy (Landoni et al, Lancet, 1997)Slide46

Fertility sparing surgery for stage IB or IA2Radical Trachelectomy and laparoscopic lymphadenectomySlide47
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ConclusionsRecent major changes in management ofOvarianEndometrialCervicalANY QUESTIONSSlide53

Any questions?www.northwestgynaecology.co.ukAt the Alexandra HospitalGail Busby: Paed GynaeRick Clayton: Gynae OncEdi Edi-Osagie: FertilityKristina Naidoo: HysteroscopyTony Smith: Urogynae/prolapse

Rick Clayton 07796267881

Group Secretary 01612482026

(Lesley)

lesley@northwestgynaecology.co.uk