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Women's Health Tip – An In-Depth Discussion with Dr. Kristopher Kimball on Gynecologic Cancer

Women's Initiative Newsletter
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What exactly is a gynecologic oncologist?

A gynecologic oncologist is a specialist in obstetrics and gynecology who, by virtue of education and training, is prepared to provide comprehensive management of patients with gynecologic cancer, including the diagnostic and therapeutic procedures necessary for the total care of the patient with gynecologic cancer. Gynecologic oncologists also are involved in research studies and clinical trials that are aimed at finding more effective treatments to further advance the treatment of gynecologic cancer and improve cure rates.

To become a gynecologic oncologist in the United States, a physician must first complete an approved four-year residency program in obstetrics and gynecology. Following this, he must complete a three-to-four year clinical fellowship in an approved gynecologic oncology training program. The additional years in a fellowship program provide the training needed for the optimal care of women with gynecologic cancer.

Advanced surgical techniques are taught during fellowship as well as training in the administration of chemotherapy and placement of brachytherapy devices for radiation therapy. After completing a fellowship, the gynecologic oncologist may practice in his specialty. To become board certified by the American Board of Obstetrics and Gynecology, an eligible candidate must pass a written and oral examination.

Studies have demonstrated that women treated by a gynecologic oncologist have a better likelihood of prolonged survival. Due to their extensive training and expertise, gynecologic oncologists can coordinate all aspects of a woman's cancer care and recovery. Gynecologic oncologists understand the impact of cancer and its treatments on women's lives, including future childbearing, sexuality and physical and emotional well-being, as well as the impact on the family.

How many women are affected in the United States each year from a gynecologic cancer? Is it common?

In general around 90,000 women per year are diagnosed with a gynecologic malignancy.

  • Endometrial cancer – 45,000 (fourth most common form of cancer in women)
  • Ovarian cancer – 25,000 (fourth most common form of cancer death in women)
  • Cervical cancer – 12,000 (uncommon in the United States but the most common cause for death from cancer in women worldwide)
  • Vulvar cancer – 5,500
  • Vaginal cancer – 4,000

What are common risk factors for gynecologic cancers?

This depends greatly on the cancer. The most important risk factors for gyn cancers are as follows:

  • Endometrial cancer: Obesity, unopposed estrogen, postmenopausal bleeding and a genetic predisposition (Lynch Syndrome)
  • Ovarian cancer: Family history of ovarian cancer or breast cancer or genetic predisposition (Lynch syndrome, or breast and ovarian cancer syndrome), and a long history of uninterrupted ovulation (no children, or no period of birth control use)
  • Cervical cancer: Persistent human papilloma virus (HPV) infection, smoking, not getting the HPV vaccination in a timely fashion and not getting regular screening (Pap test)
  • Vulvar cancer: Persistent HPV infection, smoking and chronic irritation of the area.

What is the most common gynecologic cancer? What is the most common symptom?

Endometrial cancer, or cancer of the lining of the uterus, is by far the most common gynecologic cancer. It is also one of the most commonly cured cancers. Abnormal vaginal bleeding or ANY postmenopausal bleeding should be evaluated with a biopsy and or a transvaginal ultrasound.

Are there screenings available to detect endometrial or ovarian cancer? If not, what are symptoms?

Unfortunately, there are no good screening tests for endometrial or ovarian cancer in asymptomatic women. Knowing your family history and communicating on a regular basis with your gynecologist is the best plan. Prompt evaluation of persistent symptoms is prudent.

Thankfully, endometrial cancer often presents early with symptoms such as abnormal vaginal bleeding or postmenopausal bleeding, and thus can be identified at early stages when it is the most easily cured.

Ovarian cancer, unfortunately, has less obvious specific signs or symptoms. Pelvic pain, persistent abdominal symptoms like nausea, vomiting, changes in bowel or bladder habits, early satiety and abdominal bloating or significant shortness of breath can all be related to ovarian cancer. As a result, knowing your risk for ovarian cancer is important. Women at very high risk may want to undergo additional counseling, testing or intervention.

It is important to remember that the Pap test is not a screening test for endometrial or ovarian cancer. It is only a screening test for cervical cancer.

If you are diagnosed with a gynecologic cancer, what are the common treatment options?

Like most cancers, gyn cancers are treated with a range of multiple modalities including surgery, chemotherapy or radiation. Treatment is always tailored to the individual patient and her disease status. For example, early stage cervical and endometrial cancers are most often treated with MINIMALLY INVASIVE surgery (robotic or otherwise) alone. Uncommonly, radiation and/or chemotherapy will be used instead of or in addition to surgery. Rarely, early stage ovarian cancers can be treated with surgery alone, but most commonly ovarian cancer is treated with a radical debulking surgery followed by chemotherapy. The best form of chemotherapy for some ovarian cancer patients is actually delivered into the vein and the abdomen (intraperitoneal) during treatment.

Regardless, if one is diagnosed with, or there is a suspension of, a gyn malignancy, a gynecologic oncologist should be the central component of the treatment team so that the best outcomes are possible.

Can any gynecologic cancers be prevented?

The cervical cancer vaccine (Gardasil® or Cervarix®) given prior to the onset of intercourse (recommended by the age of 11) can prevent 70% of all cervical cancer in the United States. Clinical trials may soon validate an even more effective cervical cancer vaccine. Even for women who don't get the vaccine, routine Pap testing should drastically limit cervical cancer risk. Uterine cancer and ovarian cancer can be prevented with surgical removal of the related organ. These surgeries may be recommended for some patients at high risk. Knowing your family and personal history about gynecologic, breast, colon and pancreatic cancer is the first step to knowing if you are at risk.

In evaluating a course of treatment and treatment providers, what questions should women ask?

Women should always seek out fellowship-trained and current board certified practitioners in gynecologic oncology. One should always ask if minimally invasive surgery is an option. For select advanced ovarian cancer patients, intraperitoneal chemotherapy may be available. If traditional evidence-based therapies have been exhausted, clinical trials could be considered, so it is best to be treated at a center with clinical trials available. Asking your doctor about the availability of these interventions will give you an idea of his or her abilities to best meet your needs. It never hurts to ask for a second opinion. Remember, it's your body! Don't hesitate to ask to get your symptoms addressed and your questions answered!!

Dr. Kristopher Kimball is a board certified, fellowship-trained gynecologic oncologist practicing at University of Tennessee Medical Center Cancer Institute in Knoxville, Tennessee. He received his doctorate of medicine at Vanderbilt University of Medicine. He completed his residency and fellowship at University of Alabama at Birmingham. Dr. Kimball is currently the Chair of the Gynecologic section of Robotic Surgery at UTMCK and the Associate Residency Director and Assistant Professor in the department of Obstetrics and Gynecology. He is active on the Institutional Review Board for new trials at UTMCK. He specializes in minimally invasive surgery; genetic counseling; endometrial, ovarian and cervical cancer treatment; and risk reduction for appropriate patients.

Website http://www.universitygynoncology.org

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