Our Gynecologic Cancer Team

 

In our weekly meetings, we update one another on the patient’s condition to double-assess the pre-op decision, discuss any difficulties or disagreements on diagnosis, reconfirm the decision of palliative care or hospice, and evaluate post-op results.  We put our heads together to share from different angles for more treatment options.  We also communicate and familiarize all the members on the treatment team with the patient’s condition as a way to optimize the treatment outcome.  For instance, when our ovarian cancer patient is under the care of the chemotherapy team, she is also under close surveillance from our GYN team to help her with other discomfort she might have; when a cervical cancer patient is getting radiotherapy, our GYN team takes care of side effects such as early menopause related symptoms or sexual dysfunction.  Our urology team steps in to help care for those with metastasis to extraovarian pelvic organs; the orthopedic or neurology team will be consulted in the event of bone mets related pains.  Our multidisciplinary approach has replaced the single physician decision to provide better care to our patients. 

 

Diagnosis

Pap Smear

With the introduction of Pap smear to evaluate cervical cytology, the 5-year survival has increased worldwide.  Women with sexual experience are strongly advised to get a Pap smear every year because it is proven effective as a way to detect abnormalities in the female reproductive tract. 

Human papilloma virus(HPV) test

HPV is picked up in 80% of cervical cancer cases with a sensitivity of nearly 100% in detecting the high grade squamous intra-epithelial lesions.  The combination of high specificity in Pap smear and the high sensitivity in HPV test could avoid the unnecessary transient infection related misdiagnosis caused from colposcopy.   

Colposcopy

A colposcope is used to identify visible clues suggestive of abnormal tissue. It functions as a lighted binocular microscope  to magnify the view of the cervix, vagina, and vulvar surface. Most women undergo a colposcopic examination to further investigate a cytological abnormality on their pap smears.

 

 

 
 

Treatment 

Cervical carcinoma

Aside from the cervix and uterus, this malignancy can spread by direct extension to adjacent tissues/organs and by lymphatic dissemination.  The treatment modalities include total hysterectomy and lymphadenectomy.  In the cases of involvement in other organs, then a radical surgical resection will be considered.

Thanks to increasing use of Pap smear in the past ten years, cervical cancer patients have shown the highest rate in detections of early cancer among all cancers with 78% of all their patients diagnosed at stage 0 or stage I.   Surgery is the main treatment modality with minimal side effects and good results for stage 0 and I cervical patients. 。For stage II and III patients, the treatment plan often includes concurrent chemo and radiation therapy (CCRT) to maximize the results.

In 2011, 2.3% of the nation's patients with new cervical cancer were diagnosed and treated in our center. 1,861 patients, at a median age of 45 years (19-87), with cervical cancer newly diagnosed in our center, were treated in 1990-2011.  The 5-year and 10-year survival rates are shown below.

Survial of Cervical Cancer by FIGO staging 1990-201

FIGO Stage	0	I	II	III	IV	Unclear	Total
# of patients	1,230	237	237	67	41	49	1,861
% of patients	66.1%	12.7%	12.7%	3.6%	2.2%	2.6%
5-year Survival	98.4%	93.5%	76.3%	41.6%	12.8%		90.7%
10-year Survival	95.8%	87.6%	68.2%	34.7%	12.8%		86.9%

Data source: KFSYSCC Annual Report 2011

 

161 patients with stage II and stage III cervical cancer were treated with CCRT in our hospital.  The median follow-up time was 54 months (6-214) and the 5- and 10-year suvival rates are 71.7% and 69.3%, respcetively.  

Survival of cervical cancer treated with CCRT in KFSYSCC 1990-2011

Stage	IIB	III	Total
# of patients	122	39	161
5-year survival	78.7 %	49.6%	71.7%
10-year suvival	78.7%	41.2 %	69.3 %

Data source: KFSYSCC Annual Report 2011

 

Comparisons of urvival rates of cervical cancer between KFSYSCC and all hospitals in Taiwan（%）

	KFSYSCC		Islandwide
	1990-2011	2006-2010	2006-2010
1-year survival	93.2	93.5	88.7
2-year survival	84.0	88.7	79.6
3-year survival	80.7	83.8	74.0
4-year survival	76.9	77.5	70.0
5-year survival	75.5	77.5	67.6

Data source: Health Promotion Administration, Ministry of Health and Welfare (2013)
Data source: KFSYSCC Annual Report 2011
The total number of stage 3 & 4 patients is below 20 in our center.  Therefore, data accuracy may not be reflected.  

 

Comparisons of 5-year survival by stage between KFSYSCC and all hospitals in Taiwan 2004-2010 （%）

	KFSYSCC	Island wide
Stage 0	97.1	95.5
Stage I	90.1	85.3
Stage II	78.9	66.9
Stage III	33.6	48.5
Stage IV	-- #	18.2

Data source: Health Promotion Administration, Ministry of Health and Welfare (2012)
                       KFSYSCC Annual Report 2011

-- #:  data not available due to insufficient patient number 

 

We did a comparison between the relative survival rates published by the Surveillance Epidemiology and End Results (SEER) 2004-2010 on servical cancer against our absolute 5-year survival .  Relative survival is a net survival measure representing cancer survival in the absence of other causes of death, and, generally speaking, it is higher than the corresponding absolute survival by 1-3% (KFSYSCC Annual Report 2011).

	KFSYSCC	USA SEER#
Survival Rates	77.7%	67.9%

# SEER Cancer Statistics Review 1975-2011, relative survival rates

 

Endometrial carcinoma (Uterine corpus cancer)

Endometrial cancer is the most common female genital cancer affecting primarily post-menopausal women.  It can spread to the lung, liver or bones, or to the pelvic and paraaortic lymph node chains.  Thorough explorative work-up of pathologic exams, pelvic MRI, chest x-ray, upper abdominal ultrasound or CT scan and Pap smears are done to rule out any possible distant mets.  The work-up also provides the teams with enough information for treatment planning.   The status of the lymph nodes, uterus, ovarian and the fallopian tubes is determined based on the pathology report after the surgical removal.  When a surgery is required, hysterectomy continues to be the recommended treatment which also removes the pelvic and paraaortic nodes

Ovarian Cancer

Ovarian cancer is the highest in mortality rate among all gynecological cancers.  The risk of having ovarian cancer increases with age and the ages of 50 – 60 are seen most often.  The most common symptoms of ovarian cancer are abdominal pain and fullness, intestinal discomfort, decreased appetite, and bloated abdomen.  Unfortunately, these symptoms usually do not manifest until later in the disease stage.  During the asymptomatic early stage, the tumor marker CA 125 and Transvaginal ultrasound are very useful in detecting the ovarian cancer early on to lower the mortality rate.   Risk factors of ovarian cancer are family history, age, child delivery, breastfeeding, and use of contraceptives. 

Patients of ovarian cancer will receive a series of work-up of pathologic exams, ascites aspiration or pelvic/abdominal tumor biopsy, CT of the whole abdomen, pelvic ultrasound, and chest x-ray to rule out any possible distant mets.  Based on the test results, the GYN team will determine whether to do the surgery or the chemotherapy first.  Treatment recommendations are based on the clinical stage of the disease, on age, and on patient’s performance status.   Other factors like tumor size, lymph node involvement, depth of invasion, and lymph-vascular space involvement also affect the treatment planning.  Typically a radical abdominal hysterectomy with total pelvic and selective paraaortic lymphadenectomy is the main surgical choice for ovarian cancer.  For those who can tolerate radiotherapy, intravenous general anesthesia is offered to relax the patient during the radiotherapy. 

 

 

Facing cancer

Facing cancer is facing a threat to one’s very existence.  The blow from cancer hits not just the physical being but often scars the mental and emotional presence of the patient as well as the patient’s family.  The different phases of reactions, from shocking blank to angry denial, are normal and expected. But if not managed well, they could add more pain and damage on top of the cancer itself.   Anxiety, sense of loss, fear of uncertainty, insomnia, guilt, depression, despair, and anger are among the commonly seen symptoms which require professional help as well as social support. 

 

Stress Screening

About 50% of cancer patients worldwide develop psychological symptoms but only 8 – 10 % would voice their concerns and seek help.  In our hospital, a Distress thermometer is offered to every patient upon their first visit to assess their distress level.  When necessary, the social psychotherapy team and the social workers are asked to join the multidisciplinary team to help the patient and the family cope with cancer and to safeguard the quality of life for the patient.   There are also various cancer support groups and religious support organizations that will offer to accompany the patient in their walk with cancer and fight against cancer.

 

A letter to the family

Being there for the patient means the world to the patient.  Support and company from the family and relatives are a critical part in cancer care.   Listening to the patient and respecting the patient’s wishes bring positive energy.    When a member in the family gets cancer, the rest of the family is affected in many aspects: physical, psychological, financial, and emotional, to where the whole family system could collapse.  When providing the much deserved and much needed care to the patient, the family members must remember to also provide an equal amount of care to one another and to oneself.   In the event of exhaustion or burn-out, remember to seek professional help.