Ask the Expert

Women’s health is a topic that doesn’t always get the attention it deserves. Now Suburban Hospital is working to fill the void in women’s health care with the addition of gynecologic oncology as an area of specialty for the hospital’s patients. Medical Director Dr. Annette Bicher, a respected regional gynecologic oncologist who recently joined Suburban Hospital, will be leading the hospital’s effort to further develop critical services for women. In this month’s column, Dr. Bicher takes a look at two of the most common gynecologic cancers.

What is a gynecologic oncologist?

A gynecologic oncologist is a physician who has completed four years of obstetrics and gynecology training followed by a two-to-four year fellowship in the study and treatment of cancers of the reproductive system. A gynecologic oncologist is a board-certified women’s cancer specialist. These specialists treat all variety of gynecologic conditions, including endometrial, ovarian, cervical, vulva, and vaginal cancers as well as precancerous conditions. Gynecologic oncologists provide medical and surgical care, following the patient from diagnosis to the completion of treatment.

What are the most common types of gynecologic cancers?

The three most prevalent gynecologic cancers are endometrial, ovarian and cervical cancer, with endometrial cancer being the most common.

What is endometrial cancer?

Endometrial cancer is cancer of the lining of the uterus. It is most commonly seen in post-menopausal women although it can be seen premenopausal as well. The most common symptom is bleeding or spotting between periods or after menopause. It is crucial that you tell your doctor of any unusual bleeding or spotting, especially after menopause. Sharing this information will help ensure that endometrial cancer is caught in its earliest stage.

Are there any other symptoms of endometrial cancer?

In addition to abnormal vaginal bleeding or spotting between periods or after menopause, other symptoms can include pelvic pain, pain during intercourse, and unexplained weight loss.

How is endometrial cancer diagnosed?

If your gynecologist suspects that you might have endometrial cancer, he or she will perform a biopsy to confirm the diagnosis. If endometrial cancer is found, you will most likely be referred to a gynecologic oncologist, who can discuss treatment options and recommendations for follow-up care.

Can endometrial cancer be treated successfully?

As with all cancers, the treatment plan and prognosis for endometrial cancer depends greatly on what stage the cancer is in when it is caught. Doctors use stages to determine where the cancer is, whether or not it has spread, and how far it has spread. There are four stages: stage one indicates that the cancer has not spread outside of the original area of the tumor while stage four indicates that the cancer is advanced and has spread to other parts of the body. Because endometrial cancer is often diagnosed in stage one, it is easier to cure than many other cancers.

What is the treatment for endometrial cancer?

Surgery is performed to evaluate the extent of the disease and to remove as much of the cancer as possible. In a number of cases, surgery can be performed laparoscopically, though at times it may necessitate an open procedure. Whether open or laparoscopic, a full staging procedure including evaluation of the lymph nodes is necessary. The cure rate for surgery alone approaches 80 percent with endometrial cancer and the five-year survival rate for this cancer is approximately 85 percent.

Are some women at higher risk for endometrial cancer?

Yes, some women are at a higher risk for developing this form of cancer. Risk factors include: family members who have had uterine or colon cancer, previous use of the drug Tamoxifen, previous use of estrogen replacement therapy, and exposure to excess estrogen. Exposure to excess estrogen can occur if you started your periods before the age of 12, if you entered menopause after the age of 52, if you never had a pregnancy, or if you are overweight. If you have diabetes you are also at a higher risk of developing endometrial cancer. Since the only risk factor that can really be controlled is weight, it’s important to do everything you can to control your diet and to exercise.

Which reproductive cancer is the most difficult to treat?

The toughest cancer to treat is ovarian cancer, which is cancer of the ovaries. This is the sneakiest cancer and the one that elicits the most fear in women. That’s because it is often not discovered until a later stage in the disease. What women need to remember is that every cancer is curable if it’s caught early. The key is early diagnosis.

What are the symptoms of ovarian cancer?

While once considered “the silent killer” because people believed there were no symptoms associated with ovarian cancer, experts now agree on a specific set of symptoms. Unfortunately, these symptoms continue to be overlooked or go undiagnosed, making it even more important to know what they are. The most common symptoms include a feeling of abdominal fullness or bloating that doesn’t go away, pelvic discomfort that has not been experienced before, urinary urgency or frequency, abnormal bleeding between periods, and unexplained nausea. These symptoms can be associated with a variety of conditions, so it’s important to be aware of when they come and go. If they are persistent, they should be discussed with a physician.

Is it possible to have ovarian cancer but be symptom free?

Yes. One of the reasons that ovarian cancer is so difficult to treat is that it often goes undiagnosed because of a lack of symptoms or because women discount the symptoms they do experience, thinking they are nothing. In fact, only 25 percent of women who are diagnosed with ovarian cancer will receive the diagnosis early in the disease. That means that 75 percent of women diagnosed with ovarian cancer won’t be diagnosed until the cancer is in stage 3 or 4, the most advanced stages. Because there is no diagnostic test for ovarian cancer that is 100 percent accurate, and because there is no guarantee that you will feel pelvic discomfort or that your doctor will feel a pelvic mass during a physical exam, patient awareness of symptoms helps tremendously when diagnosing this particular cancer. Never blow off persistent symptoms, no matter how trivial they seem. The good news is that ovarian cancer is nearly 90 percent curable when diagnosed in its earliest stages.

How is ovarian cancer diagnosed?

Ovarian cancer is most often diagnosed through a combination of a pelvic exam and a pelvic sonogram, or ultrasound. The diagnosis is confirmed through surgery. The surgeon may begin with a laparoscopy, a small incision in the abdomen, to remove the affected ovary for the pathologist to review immediately. Once a cancer diagnosis is confirmed, the incision will be extended so that the surgeon can determine the stage of the disease and remove as much of the cancer as possible.

What is the treatment for ovarian cancer?

Treatment for ovarian cancer most often involves a combination of surgery and chemotherapy. If caught early and with proper treatment, nearly 80 percent of cases will go into remission. Ovarian cancer does have a high rate of recurrence, however, so it’s vital that these patients be followed closely for life.

Are there risk factors for ovarian cancer?

Yes. Risk factors for ovarian cancer include: a personal or family history of breast or ovarian cancer; advanced age; inherited gene mutations, identified as BRCA1 and BRCA2 or hereditary nonpolyposis colorectal cancer (HNPCC); infertility; and nulligravity (no children).

If I am at higher risk for ovarian cancer, what can I do?

If you have risk factors for ovarian cancer, it’s important that you see a specialist who can help monitor your health and perform appropriate screening procedures. Prophylactic surgery may be recommended. If you are experiencing any of the symptoms of ovarian cancer, your physician should perform a pelvic sonogram and/or a CAT scan to get a good look at your ovaries, abdomen and pelvis. Many people talk about the CA 125 blood test as a screening test for the disease, but this blood test is non-specific. The CA 125 blood test is most useful as a marker for the disease once it’s diagnosed.

Is anything being done to help prevent these cancers or to treat them more successfully?

There is aggressive research taking place in an effort to improve the diagnosis and treatment of these cancers, especially the treatment of advanced-stage disease. New screening tools and cutting-edge surgical techniques are on the horizon. There are also numerous clinical trials under way and a gynecologic oncologist will evaluate each patient for eligibility in these trials. By raising awareness of the common symptoms of these diseases and encouraging women to begin a dialogue with their physicians, we hope to make a positive impact on overall survival.

About Dr. Bicher

Dr. Annette Bicher is a board-certified gynecologic oncologist. She received her medical degree from the University of Michigan and completed her residency in the Department of Obstetrics and Gynecology at George Washington University Hospital. She went on to fellowships in gynecologic oncology at the National Cancer Institute and the MD Anderson Cancer Center. She is an associate professor at George Washington University Hospital. Her specialty interests include the molecular genetics of ovarian cancer and clinical trials in ovarian, endometrial and cervical cancers.

Dr. Bicher’s office is located on the Suburban Outpatient Medical Center campus in the Camalier Building at 10215 Fernwood Road, Suite 300, in Bethesda. The phone number is 703.698.7100 and her Web address is http://midatlanticpelvicsurgery.com.