Q&A with Barbara Buttin, MD
Top Ten Questions About Gynecologic Cancer
1.Q: I was diagnosed with advanced ovarian cancer and know I need surgery. Can the type of surgeon I select make a difference?
A: Yes. Studies have shown that women who undergo surgery by gynecologic oncologists are more accurately diagnosed and staged, which involves determining how much cancer there is in the body and where it's located. This is critical for receiving the most appropriate and advanced treatments and has been correlated with improved survival in women with ovarian cancer.
When surgery is performed by a gynecologic oncologist, women are also more likely to be optimally debulked. Debulking means surgically removing as much of a malignant tumor as possible even if it can't be entirely eliminated, thereby increasing the effectiveness of the chemotherapy that follows. Undergoing optimal debulking or removal of all visible cancer in the abdomen has been shown to improve the chances of being cured and of achieving a long-term survival.
2. Q: I have advanced ovarian cancer and was told it is not curable. Is it worth putting myself through aggressive treatment for this?
A: Yes, it is worth going through "aggressive" treatment for this disease. Ovarian cancer is extremely sensitive to chemotherapy and more than half of women with advanced stage disease achieve a remission. The treatment is generally not very toxic and quickly alleviates many symptoms associated with the cancer. Surgery in addition to chemotherapy only increases the success rates of the treatment. Unlike for other abdominal cancers, women with advanced ovarian cancer can live many years with good quality of life. Long-term remissions are possible and some women are even cured of the disease.
3. Q: I have primary peritoneal cancer. Is this a gynecologic cancer?
A: Yes, primary peritoneal cancer arises in the lining of the abdominal organs and is essentially identical to ovarian cancer. It has the same treatment recommendations and success rates as ovarian cancer and is treated by gynecologic oncologists.
4. Q: My mom had ovarian cancer in her 50s. Am I at risk?
A: Having a family member, especially a first-degree relative with ovarian cancer, does increase the risk for you. About 10 percent of all ovarian cancer cases are related to an inherited gene mutation in the BRCA genes. Carrying such a mutation increases your risk for both ovarian and breast cancer. Your mom and/or you can get tested for this. Knowing that you have an inherited predisposition to developing these cancers can help you take active measures to prevent them including prophylactic surgery and increased surveillance options. Even in the absence of a BRCA mutation, we feel that women with a family history of ovarian cancer have some elevated risk and should have access to similar management options.
5. Q: I was diagnosed with endometrial cancer and have not had surgery yet. My doctor tells me this is not a dangerous condition and just to get a hysterectomy done.
A: This is a common misperception. While it is true that most endometrial cancers that arise in the uterine lining are not very aggressive, a small proportion of them can be life-threatening if not treated correctly. A gynecologic oncologist has the experience to treat these cancers and can decide which patient needs a simple hysterectomy versus more extensive surgical staging and possibly additional treatment with radiation or chemotherapy. Sometimes more extensive surgical staging can prevent women from having to undergo additional treatment. Initial treatment of endometrial cancer is crucial. If given a chance to recur, this disease is usually no longer curable.
6. Q: I am 30 years old and was diagnosed with endometrial cancer. I was hoping to have children but now am being told that I have to have a hysterectomy. Are there alternative treatments that could spare my fertility?
A: Yes. If you have a small tumor that is not an aggressive subtype, it is possible to treat it with progestin (hormone therapy), either with pills or with an intrauterine device (IUD). If the cancer regresses after several months of therapy, it is possible to stop the treatment and attempt pregnancy. However, endometrial cancer usually comes back if treated conservatively and ultimately will require removal of the uterus. A gynecologic oncologist can help guide you through the risks and benefits of fertility-sparing treatments and help develop a treatment plan that is right for you.
7. Q: I was diagnosed with cervical cancer even though I have always had normal Pap smears. Is that possible or is there some mistake?
A: Unfortunately, it can happen, especially with cervical cancers that arise high up in the cervical canal, which can sometimes evade detection by Pap smear. That is why an annual pelvic exam is still extremely important even if Pap smears have been normal. Luckily most early cervical cancers have a high cure rate when treated appropriately.
8. Q: I am postmenopausal and was incidentally found to have an ovarian mass measuring 5 cm on ultrasound. I feel healthy and have no other medical problems. My gynecologist suggests removal of the ovary. Could this be ovarian cancer? How can I find out before surgery?
A: Unfortunately there is no accurate way to predict whether an ovarian mass is benign or malignant short of having it removed. Blood tests including a CA125 and OVA-1 can help measure the risk and are used by gynecologists to determine if a patient with an ovarian mass or cyst should be referred to a gynecologic oncologist for surgery. The best way to manage these masses is surgical removal of the affected ovary, with a pathologist present who can determine – while you're still on the operating table - if malignancy exists. If ovarian cancer is diagnosed during surgery, a gynecologic oncologist can complete a staging procedure to determine if the cancer has spread beyond the ovary. When in doubt it is best to have a gynecologic oncologist involved in the decision-making regarding surgery.
9. Q: I have ovarian cancer and underwent surgery. My doctor is recommending chemotherapy as part of a clinical trial. Is that a good option?
A: Yes. Participation in clinical trials allows women access to the latest treatments while still getting the current standard-of-care therapy as well. No patient under these circumstances is getting an ineffective "placebo," which would be unethical.
Clinical trials are the only way to validate new treatments that may improve efficacy of the standard treatments available today. By participating you help many others. If a treatment used in trial becomes the new standard of care, you are among the first to benefit. On the other hand, if you receive the standard treatment instead of the new agent as part of the trial, you have not lost anything by participating. Patients in clinical trials usually get extra-careful disease surveillance and frequent follow-up visits. Participation remains voluntary even after you begin a treatment.
10. Q: How do I know clinical trials are safe and fair?
A: Recent high-profile concerns in gene therapy trials have focused public attention on the safety of clinical trials. Cancer clinical trials are tightly regulated and closely monitored by the federal government (http://ohsr.od.nih.gov/) to ensure that each trial is performed in the safest manner possible. All clinical trials must follow a detailed plan, or "protocol," that is written by the researchers and must be approved by the Institutional Review Board at each institution before implementation of the clinical trial. This board, which includes consumers, clergy and health professionals, reviews the protocol to try to be sure that research will not expose patients to extreme or unethical risks. Many trials assign patients to a treatment arm randomly or by chance to eliminate any possible bias and obtain valid results. This is actually the fairest way to conduct a trial. Informed consent is necessary to participate in a clinical trial and patients can withdraw their consent at any time. Talk to your physician when making a decision about whether a clinical trial is right for you.