Prevention of gynaecological cancers

Dr Linda Rogers unpacks how gynaecological cancers are screened and can be prevented.

In 1736 Benjamin Franklin said, “An ounce of prevention is worth a pound of cure,” and this is still true today. Prevention is less costly in psychological, emotional, and physical suffering, as well as healthcare costs.                          

Understanding screening

This process is where a test or investigation is done to detect malignant transformation or pre-cancers early. Characteristics of a good screening test are that it should be highly accurate (sensitive and specific), be safe and acceptable to the population being screened, and be cost-effective. 

Diseases which are suitable for a screening programme should be severe and common enough that they justify screening, and there should be a test which can detect disease before the patient becomes symptomatic, and an effective treatment for the disease when it’s detected early.

Cervical cancer

Cervical cancer is the most amenable to screening. This malignancy is responsible for the deaths of more young women aged 15–44 years in developing countries, such as SA, than any other malignancy. 

Persistent infection with cancer-causing strains of the human papillomavirus (HPV) causes cervical cancer in women whose immune systems can’t eliminate the virus, particularly smokers and those living with HIV infection. 

Until recently, screening included regular Pap smears to all sexually active women. This test scrapes cells off the surface of the cervix, to be looked at under a microscope, and abnormalities are detected. 

If you have pre-cancerous or dysplastic changes, you’ll then be referred for colposcopy, where the cervix is looked under magnification. If high-grade abnormalities are present, you can undergo a loop electrosurgical excisional procedure (LEEP), which is a minor procedure to remove abnormal cells, therefore preventing you from developing cancer.

Nowadays, a more accurate version is to test for high-risk strains of HPV on a Pap smear. Women who test positive can also be referred for colposcopy, where abnormalities can be detected and treated. This is known  as secondary prevention but we’re also now fortunate to be able to offer primary prevention, as several vaccines are available to prevent young people from acquiring HPV infection. One vaccine is offered free to all grade 5 girls in SA and is given at school. 

Tertiary prevention involves all women who have symptoms, such as abnormal bleeding and discharge, being seen and examined, to have their cancer diagnosed and treated as early as possible. 

90, 70, 90 approach

The World Health Organization has called for a 90, 70, 90 approach to eliminate cervical cancer by the year 2030. Ideally, 90% of girls under the age of 15 should be vaccinated against HPV, 70% of women with abnormal Pap smears or HPV tests should be treated, and 90% of women with cervical cancer should be offered appropriate treatment. 

Unfortunately, in SA we’re a long way from this but Australia is set to achieve this goal as they have been vaccinating and screening their female population for years.

Vulva cancer

Vulva cancer can be caused by HPV but can also arise in women who have skin diseases  of the vulva, such as lichen sclerosus. There is no formal screening programme but it’s vital that all immunocompromised women have regular check-ups to exclude HPV changes of the vulva skin, as well as of the cervix and anus. 

Similarly, all women who have lichen sclerosus should have regular check-ups.  Plus, meticulous treatment of their skin with potent topical steroid ointment, to prevent the severe itching, pain, and malignant changes that can occur as a result. 

Uterine cancer

There are many different types of uterine cancer. The more aggressive types occur in older women; unfortunately, there is no accurate or cost-effective way of screening  for these types. 

However, the less aggressive types of endometrial cancer (most common type of uterine cancer) are becoming more common, due to rising rates of obesity. They are also prevalent in post-menopausal women who have a wide oestrogen window (early menarche, late menopause, few/no pregnancies) and may have diabetes and/or high blood pressure. They can also occur in women with polycystic ovarian syndrome or Lynch syndrome. 

It’s important that all women over the age of 40 who have abnormal vaginal bleeding are appropriately investigated to exclude endometrial cancer and its precursor lesion, endometrial intraepithelial neoplasia. 

Ovarian cancer

This gynaecological malignancy has the highest mortality rate, but it’s less prevalent than cervical or uterine cancer in SA. 

Due to this disease often presenting late, with vague non-specific symptoms, such as indigestion and changes in bowel habit, many studies have looked at ways to predict which women are at risk. 

Two main tests can be done: a pelvic ultrasound to exclude abnormalities in the appearance of the ovaries, and a blood test for the tumour marker CA-125, which can be markedly raised in women with ovarian cancer. These tests haven’t been shown to be efficient or cost-effective in the general population but are used in women who have genetic syndromes (BRCA) to detect ovarian abnormalities early. 

Women with BRCA 1 or 2 should also be offered risk-reducing surgery, where their tubes and ovaries are removed between the ages of 40–45, when families are complete. 

Use of the oral contraceptive pill is another strategy which can be used to prevent both ovarian and uterine cancer. 

Dr Linda Rogers, is a gynaecological oncologist, has worked as a senior specialist in the Department of Obstetrics and Gynaecology at the University of Cape Town (UCT) and Groote Schuur Hospital (GSH) since 2009. She is assistant editor of the South African Journal of Gynaecological Oncology (SAJGO) and is a member of the South African HPV Board.                                                                                                                                          

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