By Jason Mark, MD

Q & A: Understanding Risk of Gynecological Cancers

By Jaron Mark, MD

1.) What is the importance of “knowing your risk”? a.) Family History: Family history is an important risk factor for ovarian, fallopian tube and primary peritoneal cancer, as well as for endometrial cancers. It’s important to know if multiple members of your family are affected by certain cancers, such as having two or more family members with breast cancer, pancreatic cancer, ovarian, fallopian tube, primary peritoneal or prostate cancer, as this may be a sign of having a hereditary syndrome and should prompt family members to undergo genetic counseling for consideration of genetic testing. Some endometrial cancers are related to a genetic predisposition related to Lynch syndrome (also known to increase the risk of ovarian cancer). If multiple members of the family have been affected by colon cancer or endometrial cancer, this should be a red flag to discuss genetic testing with your doctor. b.) Obesity: Obesity is associated with increased risk of ovarian cancer as well as endometrial cancer, with over 50% of endometrial cancers being attributed to obesity. c.) Age: Increased age is a risk factor for ovarian, fallopian tube and primary peritoneal cancers. d.) HPV: HPV causes over 95% of cervical cancers which highlights the importance of regular, routine pap tests to detect for cervical precancers so they can be treated before transforming into cervical cancer. HPV is also associated with development of vulvar and vaginal cancers.

2.) What is the available testing, screening and prevention? a.) Pap tests: Pap tests are used to screen for cervical and vaginal dysplasia caused by HPV in order to prevent untreated lesions from progressing into cancer. Testing is usually started initiated when women become 21 years of age. Women with a history of highgrade cervical dysplasia and those who have undergone a hysterectomy should still have vaginal pap tests to screen for vaginal dysplasia which, if high grade, can progress into vaginal cancer. b.) HPV vaccines: HPV vaccines have been around since 2006 and are approved for both boys and girls. These vaccines are very effective at reducing the risk of cervical, vulvar and vaginal cancers, as they immunize patients against the high-risk subtypes of HPV responsible for causing these cancers. In 2018, the FDA approved these vaccinations in adults up to age 45. c.) Healthy diet and lifestyle: Living a healthy lifestyle by eating a healthy well-balanced diet supports a healthy weight which in turn decreases the risk of ovarian and endometrial cancers which are associated with obesity. Living a tobacco-free life is not only important to prevent lung cancer but it is also a risk factor for cervical, vulvar and vaginal cancers. d.) Genetic testing: Genetic testing is indicated for all patients with a new diagnosis of ovarian, fallopian tube or primary peritoneal cancer. There are many different genetic testing companies and large multi-gene panels that can be used to assess for hereditary breast and ovarian cancer syndromes. Pathogenic mutations discovered on testing may warrant genetic testing on other immediate family members. Patients with endometrial cancer should also undergo genetic testing if the cancer is known to have defective mismatch repair genes which are routinely tested for while undergoing pathological evaluation after surgery.

3.) What are the differences between these cancers? What are the common/potential signs and symptoms? a.) Cervical cancer: Cervical cancer often presents with thin, clear or bloody vaginal discharge, painless vaginal bleeding or bleeding after intercourse. As the cancer progresses, symptoms can include flank pain, low back pain, leg pain, leg swelling, hematuria, rectal bleeding and vesicovaginal or rectovaginal fistulas. b.) Endometrial cancer: The majority of endometrial cancer presents with abnormal uterine bleeding such as vaginal bleeding or pinkish vaginal discharge in the menopausal period. A minority of endometrial cancer cases present with signs of uterine cavity enlargement such as pelvic pressure or pelvic pain. c.) Ovarian cancer: Ovarian cancer is the most lethal gynecologic cancer with no effective screening strategies. Most patients are diagnosed at an advanced stage because the symptoms are very subtle. Often called a “silent disease” since symptoms include decreased appetite, early satiety, bloating, increasing abdominal girth, increased urinary frequency, urgency, back pain and eventually abdominal pain or pelvic pain which most people experience at some point in their lives.

d.) Vaginal cancer: Often presents like cervical cancer with painless vaginal discharge, vaginal bleeding or bleeding after intercourse. With disease progression, these symptoms can include urinary symptoms such as dysuria, urinary retention or hematuria. Continuing disease progression can lead to gastrointestinal issues such as colonic obstruction or bloody stools. e.) Vulvar cancer: Vulvar cancer often presents with an enlarging vulvar bump or lump that can be pigmented, or ulcerated and it can itch, burn or bleed.

4.) Can cancer risk be reduced, if so, how?

Women with a strong family history of breast and/or ovarian cancer who have genetic testing and found to have a high-risk genetic mutation (such as BRCA1/2, Lynch syndrome, RAD51C/D, BRIP1) can undergo risk reducing surgery with removal of the ovaries and fallopian tubes to markedly reduce the risk of developing ovarian, fallopian tube or primary peritoneal cancer. Patients with obesity and irregular periods can reduce the risk of developing endometrial cancer by losing weight and taking contraceptives that promote regular periods. Certain patients, such as those with Lynch syndrome should undergo risk reducing surgery to remove the uterus and cervix, along with the ovaries and fallopian tubes when they are done with childbearing but usually no sooner than age 35-40 to reduce the risk of endometrial and ovarian cancer. HPV vaccination of young girls can reduce the risk of developing cervical cancer, vaginal cancer or vulvar cancer as these are often associated with HPV infection.

References 1.) ACOG Practice Bulletin on Hereditary Breast and Ovarian Cancer

Syndromes 2.) ACOG Practice Bulletin on Lynch Syndrome 3.) Onstad MA, Schmandt RE, Lu KH. Addressing the Role of Obesity in Endometrial Cancer Risk, Prevention, and Treatment. J Clin

Oncol. 2016;34(35):4225-4230. doi:10.1200/JCO.2016.69.4638 4.) Eskander, R. N., & Bristow, R. E. (2014). Gynecologic Oncology:

A Pocketbook (2015th ed.). Springer.

Jaron Mark, MD is a Gynecologic Oncologist Surgeon with the START Center. He is a member of the Bexar County Medical Society.