List of Articles
- Uterine Cancer: A Modern Approach to Surgical Management
This review discusses the current understanding of endometrial cancer and to provide guidelines for management that have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are presented. A thorough understanding of the epidemiology, pathophysiology, and diagnostic and management strategies for this type of cancer allows the gynecologists to identify women at increased risk, contribute toward risk reduction, and facilitate early diagnosis. Sentinel lymph node (SLN) mapping is based on the concept that lymph node metastasis is the result of an orderly process; that is, lymph drains in a specific pattern away from the tumor, and therefore, if the SLN, or first node, is negative for metastasis, then the nodes after the SLN, should be negative. This approach can help patients avoid the side effects associated with a complete lymphadenectomy, although disease must be thoroughly staged for accurate prognosis and determination of appropriate treatment approach. Surgeon experience, adherence to an SLN algorithm, and the use of pathologic "ultra-staging" are key factors for successful SLN mapping.
- Current Ovarian Cancer Management
Epithelial ovarian cancer is the second most common gynecologic malignancy, but is the leading cause of death from gynecologic cancer in the United States. In this discussion four updates are selected based on recent important updates in the guidelines and on debate among the experts about recent clinical trials. The topics include:
1) intraperitoneal (IP) chemotherapy,
2) CA-125 monitoring for ovarian cancer recurrence,
3) surveillance recommendations for less common ovarian histopathologies, and
4) recent changes in therapy for recurrent epithelial ovarian cancer.
During primary surgery for advanced stage epithelial ovarian cancer all attempts should be made to achieve complete cytoreduction. When this is not achievable the surgical goal should be optimal (<1cm) residual disease. All women undergoing surgery for ovarian cancer should be counseled about the clinical benefit associated with combined intravenous (IV) and intraperitoneal (IP) chemotherapy administration prior to surgery. Surgical cytoreduction (debulking) is recommended as initial treatment for many women with ovarian cancer, even those with metastatic disease. After surgical debulking, adjuvant systemic therapy (e.g. taxane/platinum) is recommended for many patients. Several different systemic regimens are recommended. Primary adjuvant therapy regimens include intravenous (IV) with (or without) intraperitoneal (IP) options. All of the regimens may be used for epithelial ovarian, primary peritoneal, and fallopian tube cancers.
- Hereditary Cancer Risk Assessment in Gynecology
The purpose of this document to review current recommendations for genetic testing for susceptibility to cancers, including ovarian, fallopian tube, breast, endometrial, and colon cancers due to inherited mutations in the BRCA genes or in the mismatch repair genes associated with hereditary nonpolyposis colon cancer (HNPCC) syndrome. Family history remains the cornerstone of patient identification. Genetic testing of appropriate individuals further enables us to identify patients with hereditary cancer syndromes, for their own benefit as well that of their entire family. Clinical genetic testing for gene mutations allows physicians to more precisely identify women who are at substantial risk of breast cancer and ovarian cancer.
- Cervical Cancer Prevention: Managing Low-Grade Cervical Neoplasia
Cervical cancer is the most common cancer in women, and caused by the human papillomavirus (HPV). Most sexually active women will acquire HPV in their lifetime. Although infection clears in most cases, it does persist in some women. Long-term persistence of HPV -- particularly with high-risk types -- has been established as a necessary cause of precancerous lesions. Cervical screening programs have been very successful in the United States, Europe, and other regions, are able to achieve broad and sustained coverage. Cervical cancer prevention can now be made even better. Substantial modifications of practice are forthcoming, motivated by improved understanding of HPV natural history and cervical carcinogenesis. The focus of this discussion is on management of atypical squamous cells of undermined significance (ASCUS) and low-grade squamous intraepithelial lesions (LSIL). This series on Cervical Cancer Prevention, will also serve as a baseline for understanding the future effects of HPV vaccination on the cervical cancer screening results.
- Cervical Cancer Prevention: Managing High-Grade Cervical Neoplasia
Given that infections with the human papillomavirus (HPV) can lead to cervical cancer, screening and diagnostic programs involving Papanicolaou smears (Pap test) and colposcopy are the standard of care in North America. As more than 80% of cervical cancers are preventable by routine screening, the United States has clearly been successful in reducing HPV-related cancers with the implementation of the cervical cancer screening programs. The purpose of this review is to discuss the current management and summarize recommendations for managing high-grade cervical neoplasia (CIN2, 3+). Areas in which improvement can be made in the recognition of high-risk features during colposcopy are also discussed. Once colposcopic technique is improved, accuracy for detection of high-risk premalignant disease increases. Carcinogenic or "high-risk" human papillomavirus (high-risk HPV) testing has become the standard triage worldwide for women with atypical squamous cells of undermined significance (ASC-US) cytology and is designated as a stand-alone follow-up option in a number of post-colposcopy and post-treatment clinical management scenarios.
- Cervical Glandular Carcinomas: Early Detection & Prevention
When different histologic types of cervical cancer are considered and trends are reexamined, it becomes apparent that observed declines are reflective of squamous cell carcinomas predominately; the rates for adenocarcinomas continue to rise. This rise in incidence may be due to the greater difficulty in screening for glandular precursor lesions that often arise high within the endocervical canal. These strategies reflect new information concerning the natural history of cervical carcinogenesis and the performance of screening and diagnostic tests, and they take into account the cost and efficacy of various treatment and follow-up options. This document will describe staging criteria and treatment for cervical glandular carcinomas. For practical purposes, it will focus on the glandular cells and adenocarcinoma histologies only
- Cervical Cancer: Early Detection and Prevention
Worldwide, cervical cancer is the second most common malignancy in women and a major cause of morbidity and mortality. Cervical cancer is gender-specific disease that disproportionately affects women in the lowest socioeconomic classes throughout the world. In 2004, the 57th World Health Assembly adopted World Health Organization's global reproductive health strategy, which identified five priority areas including "combating sexually transmitted infections"; the strategy also specifically addressed cervical cancer prevention. Screening programs have successfully reduced disease rates in developed countries that support cytology-based services; these services are too complex for most developing countries to implement. Many important advances have also taken place in the diagnosis and treatment of cervical cancer. This review also defines the strategies for diagnosis and management of abnormal cervical cytology and histology. These strategies reflect new information concerning the natural history of cervical carcinogenesis and the performance of screening and diagnostic tests. The most important component in the management of cervical cancer will always be primary prevention.
- Cervical Carcinomas: Diagnosis and Management
Globally, cervical cancer is a major health problem, with a yearly incidence of 371,000 cases and an annual death rate of 190,000. 78% of cases occur in developing countries where cervical cancer is the second most frequent cause of cancer-related death in women. Invasive cervical carcinoma, once the most common reproductive-tract cancer in the United States, has recently fallen to the rank of third most common. The purpose of this document is to describe staging criteria and treatment for cervical carcinoma. For practical purposes, it will focus on the squamous and adenocarcinoma histologies only. In addition, new evidence has documented conclusively that survival rates for women with cervical cancer improve when radiotherapy is combined with cisplatin-based chemotherapy in advanced cases.
- Breast Cancer Risk Assessment
Breast cancer biology is a topic of intensive research, and there have been huge breakthroughs in recent years. Scientific insight into estrogen-receptor biology has led to major advances in estrogen-targeted prevention and chemotherapy. Increased breast density has emerged as a dominant, detectable, and modifiable risk factor for subsequent development of breast cancer in women. The purpose of this document is to discuss clinical application of the various tools available to assess a woman's risk for breast cancer and apply in clinical practice. This review also provides a comprehensive examination of the importance of breast density as a dominant risk factor for the development of breast cancer, highlighting the role that genetics and hormones play in maintaining breast density in postmenopausal women. Future research can be directed toward the detection of preexisting conditions (such as gene mutations) that put women at risk for highly aggressive cancers. Recommendations for genetic testing are reviewed here, with a particular focus on the components of genetic counseling, identifying individuals for testing, and interpreting test results.
- Breast Cancer: Early Detection
It is estimated that 217,640 new cases of breast cancer will be diagnosed in United States this year; more than 99% of these breast cancers occur in women. Breast cancer is the most common malignancy among U.S. women and it is the second leading cause of death from cancer among American women (lung cancer is first). A woman's lifetime risk (80-year life-span) of developing breast cancer is 12.5%, or 1 in 8. Early detection of breast cancer has been shown to decrease the mortality rate. Technology continues to evolve to improve the accuracy of detection. The review also focuses on mammography and other detection techniques as screening tools to identify non-palpable lesions. This information is designed to aid practitioners in making decisions about appropriate care. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institutions or type of practices.
- Assessment & Prognostic Factors In Breast Cancer
Few breast cancer risk factors are prevalent in more than 10% to 15% of the population, although some associated with very large relative risks (e.g., mutated genes, cellular atypia). Estimates of the summary population attributable risk for breast cancer range from only 21% to 55%, leaving most of the population attributable risk for the disease unexplained. Age is one of the most important risk factors for breast cancer. Although age-adjusted incidence rates continue to rise, breast cancer mortality has fallen in the past decade in the United States. It is useful for determining the extent of the disease, predicting overall survival, and providing guidance for therapy. Clinically established prognostic factors in breast cancer and concepts and mechanisms of breast cancer metastasis are also discussed. We hope our forums help the clinicians’ better understanding of the disease process and the patient management.
- Evolution Of Surgical Management Of Breast Cancer
The surgeon has become an integral part of a multidisciplinary team who manages patients with breast carcinoma. This team includes the diagnostic radiologist, radiation oncologist, medical oncologist, and pathologist. Our resolute purpose must always be to promote the best interest of each individual patient, and not those of surgery, radiotherapy or chemotherapy. The significant contributions of investigators for breast cancer management in the 20th century established the outcome results for conservative surgical techniques to be equivalent to those of radical approaches with regard to disease-free and overall survival. Preservation of the nipple-areolar complex (NAC) while performing a mastectomy is not a new concept for the treatment of breast disease. Historically, the subcutaneous mastectomy was performed in the setting of prophylaxis for high-risk patients or to reduce breast pain, but often left much breast tissue within the skin flaps and at the base of the NAC.
- Breast Cancer Surgical Treatment Complications & Lymphedema
Complications after any operation can be minimized with thorough preoperative evaluation, meticulous technique, hemostasis, and wound closure. In addition to the standard oncologic evaluation, preoperative evaluation includes assessment of the patient's overall physiologic condition, with particular emphasis on tolerability of anesthesia, uncontrolled diabetes, hypertension, anemia, coagulopathy, or steroid dependency. The purpose of this document is to review commonly used approaches for the care of the post-mastectomy wound and addresses the complications encountered in these patients. Rehabilitation of the post-mastectomy patients produces problems of varying complexity. Pathophysiology, prevention, and management of lymphedema are also discussed. Mastectomy is a safe operation with low morbidity and mortality. Although the incidence of post-operative complications is low, physicians should be aware of the morbidity unique to mastectomy and axillary node dissection.
- Breast Cancer: Radiotherapy and Adjuvant Systemic Modalities
Radiation therapy (RT) plays an important role in management of breast cancer. In all situations, RT must be delivered in a manner that will appropriately treat the target tissues and minimize risks to adjacent normal tissues. For patients desirous of breast-conserving therapy (BCT), lumpectomy plus breast RT is typically the preferred approach, because it provides long-term survival rates equivalent to that achieved with mastectomy. This chapter also briefly reviews our current understanding of the role of adjuvant systemic therapy in the management of breast cancer in the modern era.
- Cancer, Sexual Health & Intimacy
Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. As patients move away from the acute phase of illness, healthy sexual functioning is an important step toward re-establishing their sense of well-being. Several physiologic and psychological factors specific to oncology patients (e.g. advanced disease, radical surgery, pelvic irradiation, symptoms related to menopause, pre-morbid sexual dysfunction, and negative self-concept) can promote sexual morbidity. These issues may place cancer survivors at increased risk for the development of sexual problems.
- Uterine Cancer: Early Detection
Each year approximately 36,000 women in the United States are diagnosed with endometrial cancer. There are currently no routine screening techniques for endometrial cancer in the general population. It is predominantly a disease of affluent, obese, postmenopausal women of low parity. Over the last few decades, age-standardized incidence rates have risen in most countries and in urban populations. Developing countries and Japan have incidence rates four to five times lower than western industrialized nations, with the lowest rates being in India and south Asia. There are currently no routine screening techniques for endometrial cancer in the general population. The vast majority of women have early-stage disease at diagnosis owing to postmenopausal bleeding. The American Cancer Society (ACS) has recommended that at the time of menopause, the average-risk woman should be informed about the risks for symptoms of endometrial cancer and be strongly encouraged to report any unexpected bleeding or spotting to her gynecologist. When appropriate, genetic counseling and testing should be offered.
- Staging & Management for Uterine Cancer
The carcinoma of the endometrium is easily diagnosed, but the well-differentiated cancers may be difficult to separate from advanced atypical hyperplasia. This document also outlines the rationale for the use of chemotherapy in selected patients with endometrial cancer. In a disease long regarded as the province of the surgeon and radiation oncologist, a new look at chemotherapy is producing promising results. After the diagnosis of endometrial carcinoma has been histologically confirmed, the patient should undergo a thorough evaluation. A complete physical examination can discover suspicious lymph nodes and areas of spread within the pelvis. These patients often have other medical problems that must be evaluated for their effect on treatment choices for the cancer.
- Ovarian Cancer: Early Detection
Although ovarian cancer is the second most common female reproductive cancer, preceded by cancer of the uterus, more women die from ovarian cancer than from cervical and uterine cancers combined. Ovarian cancer remains the most lethal of the gynecologic malignancies. The role of the generalist obstetricians -- gynecologists and primary care physicians in early detection of ovarian cancer is also defined in this article. Recommended cancer-screening protocols in women with high-risk is also discussed. Data suggest that currently available screening tests do not appear to be beneficial for screening low-risk, asymptomatic women. An annual gynecologic examination with an annual pelvic examination is recommended for preventive health care. Approximately one in 70 women will develop ovarian cancer in their lifetime. This increases to 4% to 6% if there is a family history in a first-degree relative.
- Staging & Surgical Management of Ovarian Cancer
Ovarian cancer remains the most lethal of gynecologic malignancies, and its mortality exceeds the combined mortality from both cervical and endometrial cancer in the United States. Ovarian malignancy is the fourth most common cause of cancer death in American women and accounts for 5% of all cancer deaths. Insightful overview of the current understanding of the ovarian malignancy as well as the areas of continuing challenges are also discussed in this series of the articles exploring different aspects of ovarian cancer. While therapy for ovarian malignancy has undergone important progress, there is growing concern about the quality of life of these patients. The contributors to this symposium include many of the experts who have advanced the management of this disease, and their articles thoughtfully describe the progress and point to future areas of reproductive research.
- Ovarian GermCell Tumors: Benign & Malignant
Germ cell tumors represent a relatively small proportion (~20%) of all ovarian tumors, but are becoming increasingly important in the clinical practice of obstetrics and gynecology. Malignant germ cell tumors of the ovary account for <5% of ovarian cancers in the United States. Most of these neoplasms occur in young women, and extirpation of the disease involves decisions concerning childbearing and probabilities of recurrence. Reproductive function following the treatment of ovarian germ cell tumors is also reviewed. Intraoperative decision making is crucial in preserving reproductive function in girls and young women with malignant ovarian germ cell tumors. The development of effective combination chemotherapy for girls and young women with malignant ovarian germ cell tumors has been one of the true success stories in medicine.
- Quality of Life & Gynecological Malignancies
In gynecologic oncology, every clinical intervention has two distinct aims. One is to produce objective improvement in the patient's medical condition and second aim, regardless of whether medical improvement is possible, is to produce amelioration of the patient's subjective symptoms. Helping the patient get better and feel better. Communication skills are essential for both. While there has been a dramatic improvement in the cure rate of gynecological malignancies and women survive longer than 5 years, with what is commonly considered a "chronic" cancer. In each phase of the illness -- diagnosis, surgery and chemotherapy with curative intent, remission and survivorship, relapse and sequential chemotherapy, bowel obstruction and end of life; quality of life (QOL) is one of the most important considerations. There has recently been a large increase in studies reporting the assessment of QOL; that has changed the field from descriptive reporting to quantitative science. History and development of QOL evaluation and various approaches to QOL assessment (psychometric based and utility based) are also discussed. It describes strategies for meaningful interpretation of QOL profiles. We hope the science of the study of QOL will be the foundation and confirmation of many of the anticipated advances for patients.
- Ovarian Cancer: Neo-Adjuvant Chemotherapy & Other Treatment Modalities
Epithelial ovarian cancer is the most lethal gynecologic malignancy in adult women. Exploratory laparotomy is required for histologic confirmation, staging and tumor debulking and should be performed by a surgeon trained in these aspects of ovarian cancer management. Because of the propensity of epithelial ovarian cancer to spread beyond the confines of the ovary, the majority of patients will require postoperative chemotherapy in an attempt to eradicate residual tissue. With advanced-stage disease (stages III and IV), postoperative combination chemotherapy with a taxane and platinum combination is the standard of care. Such treatment is capable of inducing responses in >70% of patients with residual epithelial ovarian cancer and is also capable of prolonging both disease-free and overall survival. Ongoing efforts to identify anti-angiogenesis compound to incorporate agents with novel mechanisms of action are also discussed. Role of radiotherapy and other modalities are explored. Ultimately, it is hoped, a combination of these approaches will result in an improvement in the survival of patients with this devastating disease.
- End-of-Life Care: Pain Assessment and Management
Unrelieved pain is the greatest fear among patients with a life-limiting disease. Physicians should consider the legal ramifications of inadequate pain management and understand the liability risks associated with both inadequate treatment and treatment in excess. As the fifth vital sign, pain should be assessed as frequently as the other vital signs and the findings should be well documented, for easy reference by all members of the healthcare team. This review discusses the etiology of pain at the end of life and issues in effective pain management; assessment of pain accurately through use of clinical tools and other strategies, including the use of an interpreter; and select appropriate pharmacologic and/or non-pharmacologic therapies to manage pain in patients during the end-of-life period.
- End-of-Life Care: Symptom Management (Part 1)
Symptom management is an essential element in any care setting, requiring diligent ongoing assessment and evaluation of interactions. Side effects related to treatment of symptoms must be understood and treated. The goals of symptom management for patients near the end of life are to control symptoms, promote meaningful interactions between patients and families, and facilitate peaceful deaths. Optimum treatment of symptoms involves comprehensive assessment and use of drug and non-drug interventions. It is essential that healthcare providers in all settings become prepared to provide quality care at the end of life. The physical comfort measures must continue, including frequent repositioning and oral hygiene. Emotional support of the family is imperative. This document discusses the symptoms: Fatigue and Weakness; Dyspnea; Constipation; Nausea and Vomiting.
- End-of-Life Care: Symptom Management (Part 2)
The purpose of this document is the best management of symptoms in end-of-life situations. Before initiating a symptom management approach, pharmacologic or non-pharmacologic, clinicians should allow patients time to express their thoughts and concerns. This simple step has led to better outcomes and when carried out in a supportive environment, has been almost as effective as more advanced techniques. Continual reassessment of symptoms is necessary to ensure adequate management of symptoms. It may be helpful for patients or a family member to keep a pain or symptom diary to note which measures have or have not provided relief and the duration of relief. This information will help clinicians determine the efficacy of specific therapeutic options and modify the treatment plan as necessary. The discussion of interventions in this document focuses on the care of adults. This document discusses the symptoms: Anorexia and Cachexia, Diarrhea; Sleep Disturbances; and Delirium.
- End-of-Life Care: Symptom Management (Part 3)
This course is designed to bridge the gap in knowledge of palliative care by providing an overview of the concept of palliative care and a discussion of the benefits and barriers to optimum palliative care at the end of life. Before initiating a symptom management approach, pharmacologic or non-pharmacologic, clinicians should allow patients time to express their thoughts and concerns. This simple step has led to better outcomes and when carried out in a supportive environment, has been almost as effective as more advanced techniques. Continual reassessment of symptoms is necessary to ensure adequate management of symptoms. It may be helpful for patients or a family member to keep a pain or symptom diary to note which measures have or have not provided relief and the duration of relief. This information will help clinicians determine the efficacy of specific therapeutic options and modify the treatment plan as necessary. The discussion of interventions in this document focuses on the care of adults. The issue of physician-assisted-suicide or euthanasia is likely to remain high on the medico-legal or ethical agendas of many countries in coming years. One reason, according to some experts, is a growing insistence among patients in many countries on having the final say – in all senses of the word “final” – about their medical treatment. Another reason is that people are living longer and because of medical advances increasing numbers are surviving with debilitating conditions, such as cancer and heart disease. The evidence of more than a dozen years’ experience in Oregon and two years’ data from Washington state suggests that legalized physician-assisted death provides an appropriate and ethically acceptable choice to patients who wish it and who qualify under the statutory guidelines. Along with science, empathy – the humanistic dimension – remains critical. This document discusses the symptoms: Psychosocial Care; Anxiety; Depression, Spiritual Needs; Imminent Death and Physician-Assisted Suicide.
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Dedicated to Women's and Children's Well-being and Health Care Worldwide