Gynaecological cancers

September is Gynaecological Cancer Awareness Month; Dr Nirasha Chiranjan educates us on the two most common gynaecological cancers in South Africa.

Gynaecological Cancer Awareness Month aims to encourage women to be aware of the signs and symptoms of the disease and preventive strategies. 

It’s a month that encourages women to openly speak about their health without shame or embarrassment. 

It highlights the need for better sex education amongst both men and women. 

Early detection can lead to effective treatment and a better prognosis.

What are gynaecological cancers?

Malignancies that develop in a woman’s reproductive tract. These include cervical-, ovarian-, vulvar-endometrial- and vaginal cancer. 

Cervical and endometrial cancer are the two most common cancers affecting South African women. 

Cervical cancer

The cervix is the tissue connecting the uterus to the vagina.

One in 40 women in SA are affected by cervical cancer. It’s the second most common cancer affecting women in SA after breast cancer. Cervical cancer kills at least eight women every day¹.

HPV

A common sexually transmitted virus, human papillomavirus (HPV), is the most common risk factor for cervical cancer. There are many different strains of HPV but the development of cervical cancer is linked to high-risk strains 16 and 18.  

Signs and symptoms

• Abnormal vaginal bleeding. It could be bleeding after menopause, bleeding after sex, or bleeding between periods.
• Vaginal discharge which could be copious, foul-smelling and be accompanied with pelvic pain.
• Abdomen pain and backache. 
• In advanced disease, women may complain of poor appetite; weight loss; bone pain; swelling of one of the lower legs; loss of bowel and bladder control; blood in urine or stool⁴.

Screening 

Screening is in the form of co-testing, made up of Pap smears and HPV testing. The frequency in which women get Pap smears is not the same for everyone. 

How often a woman needs a Pap smear depends on several factors, such as age, general health, and findings from previous Pap smears. Women are then placed into an average- or high-risk category. 

The best way to detect precancerous changes and early cervical cancer is to have regular screening tests. Screening women for HPV is a very effective way of preventing cervical cancer. Women between the ages of 21 – 65 should have three to five yearly Pap smears, depending on risk category. Women between the ages of 25 – 65 should be tested for HPV as well (co-testing) ^5,6,7.

Prevention

Get vaccinated 

The HPV vaccine protects against the two strains of HPV that are responsible for 70 – 80% of cervical cancers. 

There are two vaccines available in South Africa. The bivalent vaccine is approved for both girls and boys from the age of nine, and is available at most retail pharmacies and public school-based vaccination programs (only for girls, aged 9 to 12 years). 

Lifestyle modification 

Stop smoking. Smoking produces chemicals that may damage the cells of the cervix and make cancer more likely to develop. Quitting smoking or, better still, never starting, will reduce your risk.

Limit the number of sexual partners and practise safe sex to prevent HIV infection or sexually transmitted diseases. HIV positive women have a high prevalence of co-infection with HPV. If you are HIV positive, it’s important to be compliant on HAART and have regular Pap smears.

Endometrial cancer

The endometrium is the tissuelining the inner cavity of the uterus. Endometrial cancer, also known as uterine cancer, is the most common gynaecologic malignancy in developed countries and the second most common in developing countries. 

Risk factors

• Increasing age
• Unopposed oestrogen therapy
• Tamoxifen therapy (less than 1% per year) 
• Wide oestrogen window (early menarche (first occurrence of menstruation) and late menopause)).
• Nulliparity (a woman never having given birth)
• Polycystic ovarian syndrome
• Obesity
• Diabetes
• Lynch syndrome  
• Cowden syndrome 
• Family history of breast-, ovarian-, colon- and endometrial cancer⁸_. 

Signs and symptoms 

• Abnormal uterine bleeding is the cardinal symptom of endometrial cancer. 
• Incidental finding on imaging. A thickened endometrial lining is sometimes found incidentally on ultrasound, CT or MRI performed for another indication. 
• Incidental finding at hysterectomy. Endometrial carcinoma or hyperplasia is sometimes discovered incidentally when hysterectomy is performed for benign disease.

Screening and prevention 

Routine screening of asymptomatic women is not advised. Lifestyle modification includes maintaining a healthy weight, exercising regularly and healthy diet may be preventative⁹.

References:

1. CANSA: nicd.ac.za
2. Comparison of risk factors for invasive squamous cell carcinoma and adenocarcinoma of the cervix: collaborative reanalysis of individual data on 8,097 women with squamous cell carcinoma and 1,374 women with adenocarcinoma from 12 epidemiological studies.AU, International Collaboration of Epidemiological Studies of Cervical Cancer SO Int J Cancer. 2007;120(4):885. 
3. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide.AUWalboomers JM, Jacobs MV, Manos MM, Bosch FX, Kummer JA, Shah KV, Snijders PJ, Peto J, Meijer CJ, Muñoz N SO J Pathol. 1999;189(1):12. 
4. DiSaia PJ, Creasman WT. Invasive cervical cancer. In: Clinical Gynecologic Oncology, 7th ed., Mosby Elsevier, Philadelphia 2007. p.55.
5. ACOG Committee Opinion No. 463: Cervical cancer in adolescents: screening, evaluation, and management. American College of Obstetricians and Gynecologists SO Obstet Gynecol. 2010;116(2 Pt 1):469. 

MEET OUR EXPERT – Dr Nirasha Chiranjan

Dr Nirasha Chiranjan is a radiation oncologist. Her special interests are the breast, gynaecological, head and neck, and central nervous system areas. She is based at the Life Flora Hospital, Sandton Oncology (Morningside) and Ahmed Kathrada Cancer Institute.