Ovarian and Endometrial Cancers - Adam Rosenthal
Speaker key
IVInterviewer
ARAdam Rosenthal
ARHello. My name’s Adam Rosenthal and I’m a Consultant Gynaecologist at UniversityCollegeHospital, London, and my talk today was about ovarian and endometrial cancer.
IVWhat are the gynaecological cancers that GPs might see?
ARGPs are most likely to come across ovarian and endometrial cancer because those are the two commonest gynaecological cancers in the UK but they may also see cervical cancer, vulval cancer and extremely rarely vaginal cancer.
IVHow common are they and which age groups do they affect?
AROvarian cancer is not a common cancer. It probably has a lifetime risk of about one in 50 or so for any woman living in the UK, so most GPs will not come across cases very frequently, perhaps only a case every few years. Primarily ovarian cancer occurs in post-menopausal women, ie those over the age of around 50, and it’s very important to keep that in mind when you’re assessing a patient with symptoms.
Endometrial cancer has a similar lifetime risk to ovarian cancer, probably a little bit higher, so of the order of one in 50 in any woman’s lifetime, and again primarily it affects post-menopausal women.
IVHow do they usually present?
AROvarian cancer tends to present with somewhat nebulous symptoms which makes it difficult to diagnose. The symptoms are usually vague and usually intra-abdominal. There may be pelvic or abdominal discomfort, feeling full quickly after eating meals, indigestion or bloating.
Less frequently they may present with urinary or occasionally bowel dysfunction as well, but of course these are very common symptoms in post-menopausal women and the vast majority of patients complaining of such symptoms will not have ovarian cancer. The difficult job the GP has therefore is to decide who does need referral and who doesn’t.
Endometrial cancer is comparatively easy to diagnose compared to ovarian cancer. This is because it almost invariably presents with post-menopausal bleeding. It can also though present with inter-menstrual bleeding in women over the age of 40 and I think this is one of the points GPs need to keep in mind. It’s dangerous to assume that funny bleeding patterns around the time of the menopause are just down to the menopause.
If there is genuine unscheduled bleeding between periods, this should raise the suspicion of endometrial cancer in anyone over the age of 40, particularly if they have risk factors such as a raised body mass index.
IVWhat are the pitfalls for diagnosis in ovarian cancer?
ARI think these fall into two categories, basically over-diagnosis and under-diagnosis. In terms of over-diagnosis it is difficult for GPs to decide who to refer and that’s why the Department of Health guidelines can be helpful in determining this and I’m sure all GPs are aware of these. If not, then they are easily accessible on the website.
In terms of under-diagnosis I think the classic problems are assuming that symptoms in a woman over 50 are due to irritable bowel syndrome. IBS is a rare condition in women over the age of 50 in terms of it being a new diagnosis, so it’s always important to keep in the back of your mind could these symptoms be down to an ovarian cancer rather than irritable bowel syndrome.
IVAre there any questions GPs can ask patients to help assess the risk of cancer?
ARIt’s very important to remember that the strongest risk factor for ovarian cancer is a family history of the disease, so it’s crucial that all patients presenting with intra-abdominal symptoms are asked about a family history of cancer, in particular ovarian cancer, breast cancer, bowel cancer and endometrial cancer. It’s also worth asking about ethnic origin because BRCA1 and BRCA2 mutations which confer a very high risk of ovarian and breast cancer are much more prevalent in the Ashkenazi Jewish population than in the general UK population. So up to one in 40 Ashkenazi Jewish women may have a BRCA1 or BRCA2 mutation compared to around one in 500 of the general population.
As with ovarian cancer endometrial cancer family history is important but also a family history of bowel cancer because if there’s a lot of bowel cancer in the family, particularly below the age of 50, and cases of endometrial or ovarian cancer, it is possible that there’s a Lynch Syndrome mutation in the family. Lynch Syndrome is less well recognised than BRCA1 and BRCA2 but the carrier rate in the general population is around one in 500 to one to 1,000. So it’s also very well worth asking patients about a family history of relevant cancers.
If there’s any uncertainty about family history, you can always consult your local clinical genetic service and they will be willing to advise you as to whether or not patients with certain family histories require referral or not.
In addition I think if patients are presenting with bowel symptoms of any type, even if they’re not suggestive of irritable bowel syndrome, once you’ve gone through whatever you would normally do diagnostically to rule out primary pathology, if the patient still complains of symptoms, then think about the diagnosis of ovarian cancer.
IVWhere is the specialist service that GPs refer to?
AREvery hospital should have a rapid access gynaecology service so if you have a patient who you are concerned about, there should a well-recognised pathway in your area that enables you to refer in on a two week wait to a rapid access gynae clinic at your local hospital. If a cancer is diagnosed as a result of that referral, then patients will be usually for most cancers referred up to a specialist treatment centre such as UniversityCollegeHospital.
IVWhat is the prognosis?
ARUnfortunately the prognosis for ovarian cancer remains poor. Five year survival rates are typically of the order of 30% or so. However, ten year survival rates are beginning to improve as a result of more extensive surgery and better chemotherapy and new so-called biologic agents which are targeted to specific types of ovarian cancer. But overall prognosis does still remain poor and the majority of women will die from their disease eventually.
The prognosis for endometrial cancer is comparatively better than that of ovarian cancer with approximately three quarters of women surviving for five years and five year survival in endometrial cancer generally equates to cure from most women.
IVAre there going to be any advances in diagnosis and treatment in the future?
ARIn terms of ovarian cancer what we’re hopeful is that a screening programme may be introduced shortly but this is going to depend on the results of a very large study, the UKCTOCS study, which has randomised 100,000 women to screening versus 100,000 without screening. The results of this trial are expected by the end of 2015 and will inform as to whether or not the NHS decides to take on general population ovarian cancer screening
In terms of diagnosis of ovarian cancer, there are some tumour markers on the horizon, some of which are already in clinical practice in certain settings, in order to really improve the specificity of assessing women with a pelvic mass, in other words reducing the false positive rate and encouraging correct referral to a cancer centre for a pelvic mass. So a combination of different tumour markers in addition to CA-125, which is the gold standard marker, may improve the specificity and help triaging patients appropriately.
In terms of treatment of ovarian cancer, there are a number of drugs on the horizon. The other thing to mention is that people are undertaking more extensive surgery for the disease because there’s now good evidence that if you are able to remove all of the visible tumour at the first operation, then the patient will live longer.
IVWhere can GPs find out more?
ARThere should be information concerning referral on the London cancer website. In addition, if you want more information about assessing patients, then the NICE guidance on the initial diagnosis and management of ovarian cancer does contain information which is helpful in guiding who to refer and who not to refer.
I’m very happy to be contacted with any questions about gynaecological cancers on my email address which is .
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