1. Preventing and Recognizing
Gynecologic Cancers
OB/GYN at UPMC Susquehanna
John T. Comerci, MD
Brian Orr, MD

2. They can sneak up on you.
Symptoms of gynecologic cancers are often not noticeable until the cancer is in an advanced stage. This is why we want you to have all the information you need about recognizing the symptoms of the five types of gynecologic cancer.

3. Gynecologic cancers, that is.
Knowing the facts can help you recognize the sometimes silent symptoms, so treatment can begin in the earlier stages.
Symptoms of gynecologic cancers are often not noticeable until the cancer is in an advanced stage. This is why we want you to have all the information you need about recognizing the symptoms of the five types of gynecologic cancer.

4. What are gynecologic cancers?
There are five types of gynecologic cancers:
Cervical
Ovarian
Uterine
Vaginal
Vulvar
Gynecologic cancer is a blanket term that means any cancer of the female reproductive organs.
There are five types of gynecologic cancer: cervical, ovarian, uterine, vaginal and vulvar.
These cancers will affect more than 83,000 women this year, and about 28,000 will die—many because the symptoms can be subtle, or may be mistaken for other health issues.
Source: Centers for Disease Control and Prevention:

5. What you need to know now...
Risk factors
Symptoms
Diagnosis and treatment
Prevention
Regular checkups
Vaccines and diagnostic tests
Lifestyle
Our goal today is to guide you through what you need to know about gynecologic cancers. Topics we will cover include: An overview of the types of gynecological cancer and some facts about them.
Risk factors, symptoms, diagnosis and treatment for each of the five common gynecologic cancers.
Because gynecologic cancer symptoms are subtle, often described as "like a whisper," we'll pay particular attention to helping you learn to listen to your body's signals to recognize small signs before they become big problems.
We’ll also talk about steps you can take to prevent reproductive system cancers. While you can't prevent all of them, there are things you can do now, or for your daughter from an early age, to prevent some cancers that are caused by viruses.

6. Providers Gynecologists Primary care physicians Pathologists
Radiologists
Gynecologic oncologists
Oncology nurses
Oncology social workers
It takes a multidisciplinary team of medical professionals to diagnose and treat gynecologic cancers.
Your gynecologist or primary care physician will often be the first to suspect that something is wrong and needs to be investigated.
From there, pathologists and radiologists take pictures and analyze tissue samples to make a diagnosis and “stage” the cancer.
A gynecologic oncologist will then coordinate treatment.
Oncology nurses are a crucial and knowledgeable part of the process.
Oncology social workers can help a family cope with the stress of treatment.
Sources:
Cancer.net
Types of Oncologists:

7. In the U.S. in 2018 about 13,240 new cases will be diagnosed.
Cervical Cancer
In the U.S. in 2018 about 13,240 new cases will be diagnosed.
About 4,170 will die.
The good news is that it is very preventable and has a high cure rate with early diagnosis.
Cervical cancer is unique in that it is highly preventable and has a very high cure rate if caught early.
Cervical cancer used to be the leading cause of cancer death for women in the U.S. Improvements in screening and prevention have caused the mortality rate to decline significantly.
In spite of these great strides, in 2013, it is estimated that about 12,340 women in the U.S. will be diagnosed with invasive cervical cancer and about 4,000 will die. Many of them have never have had a Pap test to screen for the cancer.
Cancer of the cervix occurs more commonly in midlife. Half of the women diagnosed with the disease are between 35 and 55 years of age; 20 percent are older than 65.
This is why regular Pap tests are crucial for all women ages 21 through 70. Your doctor will help you determine the best schedule for cervical cancer screening based on your risk factors.
Source:
CDC:
National Cervical Cancer Coalition:

8. Risk Factors for Cervical Cancer
HPV infection
Smoking
A suppressed immune system
Infections with STDs, such as chlamydia
Use of IUDs
Multiple full-term pregnancies
Age at first pregnancy (younger than 17 years)
Exposure to diethylstilbestrol (DES), a form of synthetic estrogen
Family history
Every office visit should start with a personal history. A careful reading of this history can help determine if you are at higher risk for cervical cancer.
It’s important to be completely honest with your doctor when answering questions. Now is not the time to be shy or embarrassed. He or she is not there to judge, but to give you the best medical care that is appropriate to your circumstances.
All of your risk factors will be taken into account to determine your chances of developing cervical cancer.
None of them guarantee that you will get cancer, nor does a lack of these risk factors guarantee you won’t. However, it’s important for both you and your doctor to be aware of any specific risk factors you may have, so your treatment can be tailored to you.

9. HPV Infections and Cervical Cancer
Many cervical cancers are caused by the human papillomavirus (HPV).
Most sexually active men and women will be infected with HPV sometime in their lives.
All women over age 30 should have an HPV DNA test.
All females and males between the ages of 9 and 26 should have the HPV vaccine.
How many of you have heard about the link between cervical cancer and the human papillomavirus , or HPV?
Unlike many other cancers, cervical cancer is highly preventable. Many types are caused by HPV.
In addition to regular Pap tests, all women over age 30 should have an HPV DNA test.
HPV can cause changes in the cervix that can develop into cancer. At least half of all sexually active men and women get genital HPV at some point in their lives. It usually goes away on its own, but when it does not, it's considered a high-risk infection and it’s a big risk for cervical cancer.
Many HPV infections can now be prevented by a simple vaccination. This vaccine should be given to all males and females between the ages of 11 and 26.
Regular Pap tests are still important, since the vaccine does not protect against all types of HPV.
Sources:
Cancer.org:
WomensHealth.gov:

10. About the Pap Test
If your Pap test comes back abnormal, your doctor may:
Retest to verify an abnormal finding
Test for HPV
Look more closely at your cervix in a procedure called a colposcopy
Perform a test to identify abnormal cells
Order a biopsy to look at the tissue under a microscope
As I noted previously, regardless of your risk factors, regular Pap tests are crucial for early diagnosis of cervical cancer.
I’m sure everyone here is great about their annual checkup and Pap test.
You should be, because cervical cancer is highly curable if caught early. If your Pap test comes back showing the presence of abnormal cells, your doctor may do these follow-up procedures as a next step.
Treatment depends on the results of the follow-up procedures, and can include various types of surgeries, chemotherapy and radiation. The choice will depend on your age and the extent of the abnormal cells.
These are decisions you will make working closely with your doctor.

11. What are the symptoms of cervical cancer?
Abnormal bleeding
Between periods
With intercourse
After menopause
Unusual vaginal discharge
Other symptoms
Leg pain
Pelvic pain
Bleeding from the rectum or bladder
Some women have no symptoms

12. What should I do if I have just been diagnosed with cervical cancer?
Seek treatment by GYN oncologist
Discuss treatment options
Conization
Hysterectomy
Radical hysterectomy
Radiation with chemotherapy
Ask about clinical trials
Other considerations
Preserve your fertility
Preserve your ovaries

13. Ovarian Cancer
In 2018 in the U.S. about 22,240 women will be diagnosed with ovarian cancer.
About 14,070 will die.
Symptoms tend to be vague, making it difficult to detect in its earliest stages.
Ovarian cancer is the leading cause of death from gynecologic cancers in the U.S. It is estimated to affect 20,000 women this year. About half will not survive.
The reason ovarian cancer is so difficult to detect in its early stages — when it's most curable — is that the symptoms tend to be vague. They are often described as "like a whisper," and ovarian cancer is called "the silent killer."
Some experts are now saying it’s not as quiet as it seems to be, and that symptoms are simply often ignored by women who may be busy, be distracted or attribute them to something else.
Sources:
Cancer.org
Ovarian cancer has early symptoms:

14. Ovarian Cancer Risk Factors
Older women
Infertile women
Ashkenazi Jewish women
Family history
Many women get ovarian cancer in the absence of obvious risk factors. However, there may be an increased risk in:
Older women: Ovarian cancer is rare in women under 40. Half of all ovarian cancers are in women over 60. In addition, postmenopausal women who took estrogen without progesterone for more than 10 years may be at increased risk.
Infertile women: Women who have never been pregnant or have had trouble getting pregnant and undergone fertility treatments have a higher incidence of ovarian cancer.
Ashkenazi Jewish women: The proportion of hereditary ovarian cancer is higher in women of Ashkenazi heritage.
Family history is another important risk factor. Be sure your doctor is aware if any close family members — mother, sister, aunt or grandmother — on your mother's or father's side have had ovarian cancer.

15. Symptoms of Ovarian Cancer
Abnormal vaginal bleeding or discharge
Pelvic pain or pressure
Abdominal or back pain
Bloating
Loss of appetite or feeling full quickly
Changes in bowel or bladder habits
Sudden weight gain or loss
Constant fatigue
Persistent indigestion or nausea
This may seem like a lot of different symptoms, and not everyone will have all of them. These symptoms are also common to other complaints, most of them minor, which are not indicative of cancer.
However, if they are new to you, occur frequently and persist over several weeks, they may point to something more serious.
Although these symptoms are often described as “quiet” or “whispers,” research shows that women with ovarian cancer may develop symptoms several months before the diagnosis, even with early-stage disease.
It’s important to pay attention to your body, know what’s normal for you, and contact your doctor when you start experiencing unusual symptoms, even if they don’t seem very important.
Sources: ACOG.org

16. When to Consider Genetic Testing
A personal history of breast cancer diagnosed at a young age (premenopausal), breast cancer affecting both breasts (bilateral breast cancer) or both breast and ovarian cancers
A male relative with breast cancer
A family member who has both breast and ovarian cancers
A family member with bilateral breast cancer
A personal history of ovarian cancer and a close relative with ovarian cancer or premenopausal breast cancer, or both
Two or more relatives with ovarian cancer
A history of breast cancer at a young age in two or more close relatives, such as your parents, siblings and children
Knowledge is power, and knowing whether you have this genetic mutation gives you wider options for prevention.
In addition to the above risk factors, you may want to consider testing if you have a relative with a known BRCA1 or BRCA2 mutation, or if you are of Ashkenazi (Eastern European) Jewish ancestry. Genetic counseling should precede and follow any testing for the BRCA genes.
Sources:
CDC:
National Cancer Institute:
Mayo Clinic:

17. Ovarian Cancer: Importance of Surgeon
22,240 women diagnosed with ovarian cancer
Significant advantage for those women managed by a Gynecologic Oncologist:
More likely to have optimal cytoreduction
Reduction in death by 25% (p= 0.005), compared to OB/GYN and General Surgeons
Knowledge is power, and knowing whether you have this genetic mutation gives you wider options for prevention.
In addition to the above risk factors, you may want to consider testing if you have a relative with a known BRCA1 or BRCA2 mutation, or if you are of Ashkenazi (Eastern European) Jewish ancestry. Genetic counseling should precede and follow any testing for the BRCA genes.
Sources:
CDC:
National Cancer Institute:
Mayo Clinic:

18. Ovarian Cancer: Surgical Treatment for Advanced Disease
Significant survival advantage for women optimally cytoreduced.
Procedures may include:
En bloc resection of uterus, ovaries and
Bowel resection
Removal of pelvic tumor
Omentectomy diaphragmatic and peritoneal implants
Splenectomy, appendectomy
Knowledge is power, and knowing whether you have this genetic mutation gives you wider options for prevention.
In addition to the above risk factors, you may want to consider testing if you have a relative with a known BRCA1 or BRCA2 mutation, or if you are of Ashkenazi (Eastern European) Jewish ancestry. Genetic counseling should precede and follow any testing for the BRCA genes.
Sources:
CDC:
National Cancer Institute:
Mayo Clinic:

19. Ovarian Cancer: Surgical treatments for Early Stage Disease
Optimal therapy: TAH BSO + staging (including pelvic and PALN)
In younger women, reproductive conservation may be appropriate
Approximately 30% will have histologic evidence of metastatic disease
Knowledge is power, and knowing whether you have this genetic mutation gives you wider options for prevention.
In addition to the above risk factors, you may want to consider testing if you have a relative with a known BRCA1 or BRCA2 mutation, or if you are of Ashkenazi (Eastern European) Jewish ancestry. Genetic counseling should precede and follow any testing for the BRCA genes.
Sources:
CDC:
National Cancer Institute:
Mayo Clinic:

20. Ovarian Cancer: Chemotherapy
All patients should receive a taxane and a platinum
73% response rate
Median survival: 38 months for Stage III/IV
Many new agents being tested
Encourage clinical trial participation
IP chemotherapy
Knowledge is power, and knowing whether you have this genetic mutation gives you wider options for prevention.
In addition to the above risk factors, you may want to consider testing if you have a relative with a known BRCA1 or BRCA2 mutation, or if you are of Ashkenazi (Eastern European) Jewish ancestry. Genetic counseling should precede and follow any testing for the BRCA genes.
Sources:
CDC:
National Cancer Institute:
Mayo Clinic:

21. Uterine Cancer
In 2018 in the U.S. about 63,230 women will be diagnosed with uterine cancer.
About 11,350 will die.
It is the most common of the gynecologic cancers and is highly curable when detected early.
Uterine cancer is the most common of the gynecologic cancers. It is often also referred to as endometrial cancer because it usually forms in the endometrium, the lining of the uterus.
Uterine cancer is rare in women under age 30; it usually occurs after menopause.
In 2013, about 49,560 women will be diagnosed with uterine cancer and about 8,190 women will die. The cancer is more common in white women, but African-American women are more likely to die from it.
It is highly curable when detected in its early stages, which is why regular gynecological screenings are so crucial.

22. Risk Factors for Uterine Cancer
Increasing age
Unopposed estrogen
Tamoxifen
Late menopause
Nulliparity
Anovulation
Obesity (dose response)
Diabetes
Family history
Abnormal uterine bleeding 22

23. Uterine Cancer Symptoms
Vaginal bleeding after menopause
Bleeding between periods
An abnormal, watery or blood-tinged discharge from your vagina
Pelvic pain
Pain during intercourse
Feeling a mass in your pelvis
These are all symptoms of uterine cancer. Make an appointment with your doctor if you experience any of them. Don’t delay. As I said before, this a highly treatable cancer when caught early.

24. Treatments for Uterine Cancer
Surgery
Hormone therapy
Radiation
Chemotherapy
If your doctor thinks you may have endometrial cancer, he or she may perform imaging tests first, which allows for a closer view of the uterine lining. Or the doctor will perform a biopsy by using either a hysteroscopy or dilation and curettage.
The endometrial tissue will be tested for the presence of cancerous cells.
Treatment will depend upon the staging of the cancer, but can include:
Surgery
Hormone therapy
Radiation
Chemotherapy
Additional imaging tests may be performed to determine the boundaries of the cancer and confirm whether it has spread to surrounding muscles or organs.
Sources:
CDC:
Medline Plus:
Cancer.org:

25. Vaginal Cancer
In 2018 in the U.S. about 5,170 women will be diagnosed with vaginal cancer.
About 1,330 will die.
It is the rarest of all gynecological cancers and is highly curable when detected early.
Vaginal cancer is one of the rarest of all gynecologic cancers. As with cervical cancer, infection with HPV is a risk factor for getting vaginal cancer.
Vaginal cancer is highly curable in its early stages; it becomes more difficult when it has spread beyond the vagina.
Early symptoms are often non-existent or extremely vague, but regular gynecologic exams can detect it in its first stages.

26. Risk Factors for Vaginal Cancer
HPV infection
Smoking
Multiple sexual partners
Previous abnormal pap smears 26

27. Symptoms of Vaginal Cancer
Abnormal bleeding between periods, after intercourse or after menopause
Unusual, or watery vaginal discharge
A lump or mass in your vagina
Pelvic pain
Painful or frequent urination
A change in bowel habits, constipation
Any of these symptoms should send you straight to your doctor. But in particular, pay attention to abnormal vaginal bleeding because it is the most common symptom.
If you experience bleeding from the vagina that is not normal for you, consult with your doctor.

28. Types of Vaginal Cancers
Vaginal squamous cell carcinoma
Vaginal adenocarcinoma
Vaginal melanoma
Vaginal sarcoma
There are several types of vaginal cancers.
Vaginal squamous cell carcinoma. Begins in the cells that line the surface of the vagina. It is the most common type of vaginal cancer.
Vaginal adenocarcinoma. Begins in the glandular cells on the surface of the vagina.
Vaginal melanoma. Develops in the pigment-producing cells of the vagina.
Vaginal sarcoma. Develops in the connective tissue cells muscle cells in the walls of the vagina.
If your doctor suspects you may have vaginal cancer, he or she will perform a biopsy.
Treatment will depend on the stage of the cancer, but can include surgery, radiation and chemotherapy.
Sources:
Mayo Clinic:
National Institutes of Health:
Cancer.gov:
Cancer.org:

29. Treatment of Vaginal Cancer
Surgery for early stage disease
Combination of radiation and chemotherapy for more advanced disease
There are several types of vaginal cancers.
Vaginal squamous cell carcinoma. Begins in the cells that line the surface of the vagina. It is the most common type of vaginal cancer.
Vaginal adenocarcinoma. Begins in the glandular cells on the surface of the vagina.
Vaginal melanoma. Develops in the pigment-producing cells of the vagina.
Vaginal sarcoma. Develops in the connective tissue cells muscle cells in the walls of the vagina.
If your doctor suspects you may have vaginal cancer, he or she will perform a biopsy.
Treatment will depend on the stage of the cancer, but can include surgery, radiation and chemotherapy.
Sources:
Mayo Clinic:
National Institutes of Health:
Cancer.gov:
Cancer.org:

30. In 2018 about 6,190 women will be diagnosed
Vulvar Cancer
In 2018 about 6,190 women will be diagnosed
with vulvar cancer.
About 1,200 will die.
Vulvar cancers are highly treatable when caught early. Regular gynecologic exams will detect most vulvar cancers in their very early stages.
Vulvar cancer is another rare type of cancer. It is slow-growing and develops slowly over several years.
The vulva is the outer part of the female genital organs. It has two folds of skin, called the labia. Vulvar cancer most often occurs on the inner edges of the labia. Most vulvar cancers are skin cancers.
It is estimated that this year about 4,700 women will be diagnosed with vulvar cancer, and about 990 will die.
Vulvar cancers are highly treatable when caught early. Regular gynecologic exams will detect most vulvar cancers in their very early stages.
There are several types of vulvar cancer.
The most common are vulvar intraepithelial neoplasia (VIN), invasive squamous cell cancer of the vulva, vulvar melanoma, Bartholin gland cancer and Paget disease.

31. Risk Factors for Vulvar Cancer
HPV infection
Smoking
Immune system suppression
Lichen sclerosus 31

32. Symptoms of Vulvar Cancer
Itching that doesn't go away
Changes in color or texture of the skin in the vulvar region
Feeling a lump
The appearance of pimple- or wart-like bumps
Open sores or ulcers
Abnormal bleeding
Because so many of the symptoms involve changes that are external and can be seen upon a visual exam, it's important to get regular gynecological checkups so your doctor can check for these changes.
As with cervical and vaginal cancers, some vulvar cancers are caused by HPV infections, which the HPV vaccine can help prevent.
If your doctor suspects that you may have vulvar cancer, he or she will perform a biopsy. If it is positive, further tests will be needed to determine the stage of the cancer and show whether it has spread to other parts of the body.
Treatment will depend on the stage of the cancer, but can include surgery, radiation and chemotherapy.
Sources:
National Institutes of Health:
Centers for Disease Control and Prevention:
Cancer.org.:
Mayo Clinic:

33. Treatment of Vulvar Cancer
Surgical resection of the vulvar lesion
Either sentinel lymph node or complete dissection of one or both groin nodes
For advanced disease involving the urethra or anus then combination radiation and chemotherapy followed by surgery if resectable
Because so many of the symptoms involve changes that are external and can be seen upon a visual exam, it's important to get regular gynecological checkups so your doctor can check for these changes.
As with cervical and vaginal cancers, some vulvar cancers are caused by HPV infections, which the HPV vaccine can help prevent.
If your doctor suspects that you may have vulvar cancer, he or she will perform a biopsy. If it is positive, further tests will be needed to determine the stage of the cancer and show whether it has spread to other parts of the body.
Treatment will depend on the stage of the cancer, but can include surgery, radiation and chemotherapy.
Sources:
National Institutes of Health:
Centers for Disease Control and Prevention:
Cancer.org.:
Mayo Clinic:

34. Your Lifestyle Matters
Be physically active
Have regular physical exams
Maintain a healthy weight
Use birth control
Don't smoke
Report changes
Manage stress
Tubal ligation
Eat a healthy diet
Breastfeeding
Use sunscreen
Pregnancy
Drink alcohol in moderation
There are specific suggestions for preventing some of these cancers, but a healthy lifestyle can help decrease your chances of getting sick from all cancers.
What you can do every day (go through list):
That last suggestion may be a bit controversial for some, but, in fact, period suppression has been shown to reduce the risk of ovarian and uterine cancer.
All of these behaviors will contribute to overall good health and have been shown to help prevent some cancers.
Sources: Cancer.gov

35. Here’s the Problem
Many of the symptoms of gynecologic cancers are vague.
Many of these symptoms are also present in much less serious conditions.
Many of these symptoms are easy for a busy woman to ignore.
When you’re talking about vague-seeming symptoms like “bloating,” “tiredness,” and “just not feeling right,” it can be hard to get a busy woman to sit up and take notice.
It doesn’t help when even expert resources admit that, yes, these symptoms are also common in other, much less serious conditions, and aren’t uncommon in any women trying to juggle work, home and family.
However, busy as you may be, stressed as you may be, it’s important to listen to your body and ask these questions:
Did this symptom, or symptoms, come on suddenly?
Does it occur daily?
Has it persisted for two or more weeks?
If the answer is “yes,” see your doctor!
Sources: Cancer.org

36. SEE YOUR DOCTOR REGULARLY!
One Important Message
SEE YOUR DOCTOR REGULARLY!
How many of you have picked up on the one theme that has run through this entire presentation?
Cervical cancer is highly curable if caught early. Regular Pap tests can detect it in its earliest stages.
Vaginal cancer and vulvar cancers are often detected during physical exams.
Cervical and uterine cancers have vague symptoms that only a medical professional may recognize.
Most gynecologic cancers can be caught early on with regular physical exams. If you do only one thing for your reproductive health, see your gynecologist at least once a year.
Remember to discuss your risk factors with your doctor at every exam. If you show increased risk due to family history, DES exposure, HPV infection or other factors, you may need to be seen more often than the average annual screening.
The best prognosis for beating cancer is early detection, so this will give you the best chance of surviving one of the five gynecologic cancers.

37. Magee-Womens Research Institute (MWRI)
The largest independent research institute in the U.S. focused exclusively on women’s health.
More than 20 areas of research in women’s health and reproductive biology
More than 300 researchers and staff
Strong partnerships with University of Pittsburgh and Magee-Women’s Hospital of UPMC
Women’s Cancer Research Center (WCRC) is a collaborative effort of MWRI and UPMC Hillman Cancer Center
The WCRC brings together more than 170 experts working toward a cancer-free future

38. Examples of some of the work done at MWRI
Performing cutting edge studies on placental defense against Zika.
Using Big Data, the Magee Obstetrical Maternal Infant (MOMI) Database of more than 200,000 births in the last 22 years, and its new Biobank of DNA and Tissue samples, to provide a longitudinal view of generational births that will be used to eradicate infant mortality in the future.
Working on new methods to decrease the spread of HIV in Africa through our Microbicide Trials Network, where 11,000 women are enrolled in trials in 6 countries.
Testing revolutionary urogynecological treatments for debilitating prolapse.
Working on new methods that may offer hope for young cancer patients facing permanent infertility from chemotherapy, to have biological children someday.
Researching the development of vaccines and identifying biomarkers for earlier detection of ovarian cancer, a deadly and silent killer.

39. Questions?
OB/GYN at UPMC Susquehanna Health Innovation Center 740 High Street, Suite 1004, Williamsport Dr. John Comerci