Clinical Review

Gynecologic care of the cancer patient

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References

Cancer survivors often face an even greater risk of CVD than the general population because of the cardiotoxic effects of some cancer therapies. Thus, evaluating cancer survivors for cardiovascular risk factors is essential to their management.

Many agents, including HRT, have been evaluated for the management of hyperlipidemia. The NCEP recommends that statin drugs, rather than HRT, be the first-line treatment for this condition because they have been found to be more effective in lowering low-density lipoprotein (LDL) cholesterol. In fact, recent studies have questioned the safety of estrogen in the secondary prevention of CVD in women with established cardiac disease.7

Endometrial cancer. To date, there is no proven method of screening for endometrial cancer in tamoxifen-treated patients. In these women, the expected annual risk is 2 per 1,000.58 Although this risk is low, endometrial cancer remains a major concern for patients taking the drug.

Endometrial sampling should be reserved for patients who are experiencing abnormal bleeding. In a recent prospective trial measuring the incidence of abnormal endometrial pathology in 111 tamoxifen-treated patients, Barakat et al concluded that the utility of endometrial biopsy is limited in this population.59 In another trial, Gibson and colleagues noted that all cases of endometrial carcinoma detected by dilatation and curettage (D&C) were found in tamoxifen-treated patients who presented with abnormal bleeding.60

Ultrasound also has been evaluated as a screening technique in this population. An endometrial thickness of 8 mm or more is considered abnormal, although this guideline is under evaluation. Hann et al reported that although most tamoxifen-treated women are asymptomatic, endometrial polyps were found in 33% of cases with a lining thicker than 8 mm. In addition, they found a correlation between endometrial thickness and duration of tamoxifen use.61

Another study recently found that transvaginal sonography has a high false-positive rate, even when the cut-off for endometrial thickness is 10 mm instead of 8 mm.62 In this study, 1 asymptomatic endometrial cancer was found. The authors concluded that this low yield does not justify the increased iatrogenic morbidity of transvaginal ultrasound screening in the tamoxifen-treated patient.

Conclusion

This review of the cancer patient’s needs underscores the principle that all patients, regardless of medical history, need thorough evaluations to identify risk factors for other disease entities. As such, all women should undergo an annual examination so that preventive measures such as cardiovascular health assessment, bone densitometry, mammography, colonoscopy, and screening for familial health risks also can be undertaken.

However, a thorough medical evaluation often is not performed in the cancer survivor because her cancer is the focus of most of her physician visits. Thus, preventive measures such as those outlined above are overlooked, putting her at increased risk for fracture, cardiovascular disease, and other dysplasia or malignancies.

Gynecologic care of the cancer patient requires an understanding of the numerous issues that cancer survivors face—many of which are no different than those faced by their healthy counterparts. While a multidisciplinary approach may be required, such health care ideally should be coordinated by a primary-care physician. This responsibility often falls to the gynecologist or internist.

In addition, an understanding of the chemotherapeutic regimens, the effects of radiation therapy, and psychological factors can help the clinician identify or anticipate the problems unique to the cancer patient. The physician’s ability to validate a patient’s concerns, dispel myths, and provide information about treatment options can ease her anxiety and maximize physical and psychological well-being.

The authors report no financial relationship with any companies whose products are mentioned in this article.