Clinical Review

Gynecologic care of the cancer patient

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References

Oral contraceptives (OCs) have been evaluated for their possible role in the prevention of ovarian cancer in the general and high-risk populations. It is estimated that OC use may reduce the risk of hereditary ovarian cancer by as much as 60%.39 However, the benefits of this therapy need to be weighed against the possible increased risk of breast cancer in patients with BRCA1 and BRCA2 mutations.40,41

Due to the low sensitivity and specificity of available screening tests and the relatively low prevalence of ovarian cancer in the general population, routine screening is not recommended, except in women who are at increased risk. Such high-risk women include those who have a personal or family history of ovarian or breast cancer, known mutations in the BRCA1 and BRCA2 genes, or who are of Ashkenazi Jewish descent with personal or family histories of breast or ovarian cancer or both.

No single screening modality has been proven effective. Studies evaluating the role of semiannual pelvic examinations in conjunction with transvaginal sonography (TVS) and CA125 evaluations are under way.42 These modalities currently are the best options in the high-risk population.43-45

For the patient identified as having HNPCC syndrome, screening should include annual endometrial biopsies, breast cancer screening, ovarian cancer screening (as above), colonoscopy, and urine cytology. Prophylactic hysterectomy and oophorectomy may be considered to reduce the gynecologic cancer risks.46

TABLE 3 summarizes surveillance options for women at high risk for familial cancers. Since screening options are limited in sensitivity and specificity, the guidelines are based on expert opinion rather than randomized studies.47

TABLE 2

Cancer risk conferred by inherited mutations in BRCA1 and BRCA2

CANCERRISKS
BreastUp to 87% by age 70; 33% to 50% by age 50
BRCA1 or BRCA2Risk of contralateral breast cancer, 64% by age 70; 25% within 5 years
Ovarian
BRCA128% to 44% by age 70 to 80
BRCA227% by age 70 10-fold increased risk following breast cancer
Colon
BRCA13.3-fold increased risk
Source: Frank TS. Hereditary risk of breast and ovarian carcinoma: the role of the oncologist. Oncologist. 1998;3:403-412

TABLE 3

Screening options for patients at high risk for familial cancers

INTERVENTIONRECOMMENDATIONQUALITY OF EVIDENCE*COMMENTS
BREAST CANCER
Self-examinationTeach BSELevel III evidence Expert opinion onlyBenefits not proven
Clinician breast examinationAnnually or semiannuallyLevel III evidence Expert opinion onlyBenefits not proven
MammographyAnnually, beginning at age 25 to 35Level III evidence Expert opinion onlyRisks and benefits not established for women under age 50
OVARIAN CANCER
Semiannual pelvic examination, TVS, and CA125Semiannually, beginning at age 25 to 35Level III evidence Expert opinion onlyBenefit of TVS, CA125, and pelvic exam levels not proven. Consider prophylactic surgery; significant reduction in risk. Lower estimated ovarian cancer risk in carriers of BRCA2 mutations than in those with BRCA1 mutations.
COLON CANCER
Colonoscopy every 5 to 10 years, hemoccult annuallyAll patients beginning at age 50. Sigmoidoscopy every 3 to 5 years may be effective in a low-risk population.Evidence from average-risk populations includes a Level I randomization trial (fecal blood test) and a Level II-2 case- control study (sigmoidoscogy)If the patient has HNPCC, consider prophylactic total abdominal hysterectomy with bilateral salpingo-oophorectomy
Adapted from: Burke et al. Recommendations for follow-up care of individuals with an inherited predisposition to cancer I. Hereditary nonpolyposis colon cancer. JAMA. 1997;277(11):915-919.
*Denotes the highest-quality trial performed
Level I = highest-quality trials
Level II = intermediate-quality (nonrandomized) trials and observational studies (Level II-2 indicates a case-control study)
Level III = lowest-quality (expert opinion and case reports)

Sexual health

Sexual dysfunction is one of the more common, enduring consequences of cancer treatment. Approximately half of the women who survive breast or a gynecologic cancer report severe, long-lasting sexual problems.48 Studies have shown that sexuality issues are prevalent among cancer survivors in general. Anderson reports sexual-functioning morbidity occurs in up to 90% of women with the most prevalent types of cancer.49 Other authors estimate that post-treatment sexual dysfunction ranges from 30% to 100%.50 Disease-free breast cancer survivors admit that sexual problems persist as bothersome and disheartening exceptions to their generally high level of functioning. For other cancers such as Hodgkin’s disease, at least 25% of patients are left with a sexual dysfunction.51

For patients who have vaginal stenosis or shortening due to surgery or irradiation for gynecologic or colorectal cancers, the use of dilators as early as possible is essential to maximize vaginal length and treatment success. In general, initial counseling about the use of these devices is provided by the surgical or radiation oncologist.

Ideally, however, patients with cancer—especially disease involving the vaginal, perineal, and anal areas—who require extensive surgery or irradiation will have had a sexual-health consultation before treatment. At our institution, the patient initially is evaluated by a psychologist, who is a licensed sex therapist, and a gynecologist so that both physical and psychological components can be assessed and a course of treatment planned.