Clinical Review

Gynecologic care of the cancer patient

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References

Overall, the ideal approach to sexual dysfunction in the cancer patient is:

  • Validating the patient’s need for a sexual relationship;
  • Assisting in identifying those factors contributing to the difficulty; and
  • Conducting a pretreatment evaluation with the patient and her partner, if possible.

The annual exam

Cervical cancer screening. The most common type of cancer in women is cervical cancer, with approximately 450,000 new cases reported worldwide each year. Screening with Pap smears and advanced colposcopic techniques has dramatically decreased mortality from this disease in developed countries. Further, testing for human Papillomavirus (HPV), in addition to regular Pap smear screening, has improved the sensitivity of cervical cancer screening.52,53

While physicians agree that all women should begin Pap smear evaluations annually beginning at age 18 or at the onset of sexual activity, some argue there may be a role for HPV testing at the initial screening, as well, to reduce the false-negative rate and help identify at-risk individuals earlier. Patients who already have cancer and may be immunosuppressed as a result of their treatment may be at higher risk for HPV, thus warranting routine HPV screening. (In such women, genital warts may be diffuse, requiring surgical treatment.)

Colonoscopy. Colon cancer is the third most common cancer in women. Risk factors include advanced age, living in an industrialized country, a diet high in fat and cholesterol, genetic premalignant polyposis syndromes, a family history of colon cancer or inflammatory bowel disease, and a history of intestinal adenomatous polyps.47

Colonoscopy is recommended for all patients beginning at age 50, with a frequency of every 10 years for those at average risk. Women with any of the risk factors noted above, a personal history of breast or ovarian cancer, or both, should undergo more frequent screening.

Digital rectal examination, as well as a hemoccult, should be part of the annual examination.

Osteoporosis. Osteoporosis is a leading cause of nursing-home admissions and a leading cause of morbidity in post-menopausal women. The cancer survivor needs to be evaluated thoroughly for osteoporosis risk factors, particularly since many of these women will have entered menopause prematurely. Further, these patients may have additional risks associated with treatment with steroids, chemotherapeutic agents, or radiation.

Preventive measures, including bone densitometry and the measurement of bone turnover markers, should be performed at menopause or earlier in cancer survivors. Currently, the National Osteoporosis Foundation recommends HRT as the firstline agent for the treatment and prevention of osteoporosis in the general population. In cancer patients, however, particularly those with estrogen-sensitive cancers, HRT may not be a viable option. Alternatives include antiresorptive agents such as raloxifene hydrochloride, a selective estrogen receptor modulator (SERM). The Multiple Outcomes of Raloxifene Evaluation trial (MORE) found that raloxifene reduced vertebral fracture incidence by approximately 50%, had no adverse gynecologic effects, and may decrease the risk of breast cancer.54

Although it was approved for the treatment of osteoporosis, alendronate, a bisphosphonate with antiresorptive effects, can be used in lower doses as a preventive agent as well.55,56 When alendronate was given, the relative risk for fracture was reduced by 50% in a group of women considered at high risk based on known low bone mass and a history of at least 1 vertebral fracture.54 Incidence of hip fractures also was significantly reduced. However, at the typical dose of 5 to 10 mg daily, alendronate has not been well tolerated, primarily due to gastrointestinal effects. More recently, a 35-mg and 70-mg weekly dose have been used successfully and are better tolerated.

Bone turnover markers, such as urinary N-telopeptide (NTX) levels, can be used to determine if treatment should be instituted and whether it has been effective. NTX is an indicator of what a patient’s bone density will be if she remains untreated or continues her current regimen. A significantly elevated NTX, i.e., 38 BCE (bone collagen excretion), indicates the presence of a metabolic disease, and the clinician should consider initiating antiresorptive therapy.

Regardless of bone mass or bone turnover rates, calcium and vitamin D supplementation should be encouraged. Generally, post-menopausal women should be advised to take 1,000 to 1,500 mg of calcium per day as well as 400 to 800 IU of vitamin D.

Cardiovascular disease. The leading cause of death in postmenopausal women is cardiovascular disease (CVD). Over the remainder of her lifetime, a 50-year-old woman has a 46% probability of developing CVD and a 31% chance of dying from it. The National Cholesterol Education Program (NCEP) Expert Panel [Adult Treatment Panel III (ATP III)] has proposed an algorithm for CVD risk-factor stratification with the goal of treating high-risk women more aggressively.57 When high-density lipoprotein (HDL) cholesterol levels are low, women face a greater risk of CVD than men do at similar levels. Diabetes and hypertriglyceridemia also impart a greater risk of CVD in women.