Hi, I'm Dr. Pamela Soliman, a professor in the department
of Gynecologic Oncology here at MD Anderson Cancer Center.
I'm joined today with one of my esteemed colleagues, Dr.
Shannon Westin, who's also a professor in the department of
Gynecologic Oncology.
Thank you so much for joining us for this Cancerwise
podcast today.
I'm so excited to be here.
Thanks for having me.
We're here to talk about what women should know about
gynecologic cancers.
Shannon, maybe tell us a little bit about what you do as
gyn oncologist.
Yeah, I mean, I think it's really important to understand
because it can be really confusing about what exactly we
do. So, gynecologic oncologists are the
ultimate doctor, right?
So, we do surgery and we give treatment for
gynecologic cancers.
But, it's important to know that we don't treat all women's
cancers. We typically will treat below-the-belt women's
cancers. So, uterine cancer, ovarian cancer, cervical,
vaginal, vulvar.
We do not treat breast cancer.
But, I think that we would all agree that as gynecologic
oncologists, we have the opportunity to provide the most
comprehensive care because of the way that we touch all
pieces of the woman's journey.
And then maybe talk a little bit about which cancers
you treat, and we can talk about how to screen for them
or what people should know in general.
Sure. I mean, I can start with just our cancers
in general. So, let's start with the reproductive
organs, right? So, we have the uterus.
And that is where a baby will grow when we have a
pregnancy.
But, the cancer can start either inside the uterine lining,
which is called the endometrium, or in the muscle wall,
which can be called a sarcoma.
We also can see cancers that start just in the cervix,
so on the outside of the womb, and then
even going out to the external female genitalia,
like the vulva and the vagina.
And then finally, we can see cancers in the ovary,
or along the fallopian tube, or in the inside lining of
the abdomen, which is called the peritoneum.
And those are all kind of loosely grouped as something
called ovarian cancer and treated the same.
So, let me ask you this: I think there's a lot of confusion
out in the community around the Pap tests and what it
actually can show.
So, that's a great question and something that we're often
asked, like, "Oh, I had a Pap smear.
Doesn't that screen for ovarian cancer?" And the reality
is, no, it doesn't, OK?
So, the main reason you have a Pap smear is for
early detection of a pre-cancer or dysplasia
so that we can prevent cervix cancer.
I think going to the doctor also enables you to have a
pelvic exam and have a discussion about any symptoms
that you're looking at or anything different, and those can
be helpful to find some of the other gynecologic cancers.
And that makes sense. And I guess the other the question
that comes up then is: how does somebody out in the
community get screened for, say, ovarian, or peritoneal
or fallopian tube cancer?
Are there any mechanisms that work well for that?
Yeah. No, that's again, something that we're asked
commonly. So, endometrial cancer is the
most common gynecologic cancer that we see.
Risk factors include being overweight or obese,
things like diabetes, hypertension,
something called PCOS or polycystic ovarian syndrome.
So, there isn't a screening test for endometrial cancer,
but endometrial cancer often presents with
a symptom that women recognized as abnormal.
And so, we tell women if you're having irregular
periods, so you're bleeding in between your periods,
they're very unpredictable, all of a sudden they change
and they're very heavy, that's something you should let
your doctor know about.
In women who've already gone through menopause, any
bleeding at all, so even a drop of blood, that's like a red
flag that something may be going on.
So, even though there isn't a screening test, these,
like, physical signs that most women recognize as abnormal
will lead them to go to their doctor.
And if they go to their doctor and they report these
things, then they'll have an evaluation, either a pelvic
ultrasound to look at the lining of the uterus, or
sometimes an office endometrial biopsy where we take a
small straw, put it inside the uterus, and then take out
some cells. And that's a way that we can find endometrial
cancer. And fortunately, because people recognize these
are abnormal symptoms, most women are diagnosed with
early-stage disease.
Maybe switch gears and talk a little bit about ovarian
cancer screening and kind of what's going on with that.
Yeah, I mean I think ovary cancer has been tough because
there are some ways that we can screen for it.
You already mentioned some of them. Right.
So an ultrasound is a way.
We can use a blood test, something called a CA-125,
which may or may not be elevated in the setting of ovarian
cancer. But, I think the issue is we've not been
able to find a universal screening.
So, there's no recommendation at this point,
if you go to your regular gynecologist or your regular
internal medicine physician, that there's anything that
should be done to look for ovarian cancer
if you're without symptoms or any other history.
So, the symptoms that would raise our eyebrows or make
us concerned that there could be the
presence of ovarian cancer is kind of
subtle. They're symptoms that are often really easy to
blow off, right? So, abdominal pain, nausea,
bloating, kind of, not fitting quite well in our clothes,
weight gain, weight loss.
And it's easy to blow it off and be like, "Oh, maybe I'm
lactose intolerant, or I need more fiber in my diet, or I'm
allergic to gluten." You know?
So, I think it's very easy to put those symptoms off
on something else. But, if we're seeing those types of
persistent symptoms, then we would want to move forward
to do some screening. And that's the same things that you
just talked about. So, ultrasound, lab and really
more advanced imaging.
So, you know we personally love as gynecologic oncologists
when someone has gotten a CT, a CAT scan of the abdomen
and pelvis, because we get a really good look and can
understand what's going on.
I think, you know, in a person that has
increased risk, and this would be people
that have either a genetic
predisposition to the development of ovarian cancer
or other extensive exposure to estrogen,
so early menarche, early start of menses
or late menopause, so when everything
stops, if they haven't had a lot of
kids, so they've been exposed to estrogen for longer times,
you know, or if they're taking estrogen, you
know, those types of things could put us at higher risk and
may warrant a little bit more careful screening.
I would love to, kind of, to switch gears a
little bit and talk about the genetics.
Do you want to tackle the genetics of endometrial cancer
because that's something you've done a lot of work in?
Yeah. So, I think, you know, when many patients
are diagnosed with cancer in general, the first thing they
want to know is, "Oh, why did I get this?
Are my kids at risk for getting this?
You know, is this genetic?" And for most women
with endometrial cancer, fortunately, it's not genetic.
And there are other risk factors like we talked about:
overweight, obesity and things like that.
So, if you take all women that have endometrial
cancer, only about 2% to 3% are caused
by a genetic syndrome, something called Lynch syndrome.
It's a gene that we carry, and we can
pass on to our children, about 50% chance of passing
it on to your children, that increases your risk for
several cancers, including endometrial cancer.
So, if a person has Lynch syndrome,
then their lifetime risk of developing uterine cancer
is about 60%.
So, many women will get uterine cancer.
And then, it also increases your risk for other cancers.
So, among the gynecologic cancers there is a slight
increase in ovarian cancer.
So, we didn't really talk about it.
But the general population of risk of ovarian cancer is a
little bit less than 2%.
So, if you're not in the high-risk category, the risk
you're going to get it is relatively low to other cancer
types. But, if you have Lynch syndrome, it can be
up to 10% lifetime risk.
So, it does increase for that.
In women that have a genetic mutation,
then we can also test their children.
So, that gives us an opportunity to understand whether
their siblings or their children are also affected.
And if they are, then it allows us to implement
a different screening and a more proactive management
style. So, for example, if my mom had uterine
cancer years ago, and she was tested and found to have
Lynch syndrome, and then I got tested, and I know I have
it, but I don't have cancer, what we generally do
is recommend an endometrial biopsy annually.
It also increases your risk for colon cancer.
So, we do colon cancer screening earlier
and more frequently than the general population.
And then, once patients are finished with childbearing, we
actually offer them preventative surgery.
So, you can say, "OK, I'm 40 years old.
I've had my kids. I want to go ahead and have a
hysterectomy to prevent a future uterine cancer."
And we see something similar with ovarian, peritoneal and
fallopian tube cancer, where I think many of our listeners
will be familiar with something called BRCA.
And there's two pieces of BRCA.
We have BRCA 1 and BRCA 2, as well
as some more rare genetic syndromes that we can
see, or abnormalities in the genes like RAD51C,
RAD51D. But, the bottom line is when you have this
abnormality in the gene, it puts you at a higher risk of
the development of cancer, specifically breast cancer, as
well as ovary, peritoneal and fallopian tube cancers.
And just like you said, you know, if you
have a family history of any of the
cancers associated with BRCA, you may be at an increased
risk. And specifically, when we talk about family history,
we're looking at some specific features.
We look for first-degree relatives, so, like, your
parent or your sibling.
We look at the age at which that cancer develops.
So, younger age at the development of cancer is concerning
for a potential hereditary syndrome.
And then, we look to see the pattern within the family.
Are there multiple of these types of cancers or even
have you already had breast cancer?
You might be at an increased risk of developing ovarian
cancer. And so, when we know that we have these
abnormalities it's a simple test, right?
We can test your blood or test your saliva
and look for the, kind of, most common genes that are
abnormal. And if we identify that and you do not have
cancer, just like what was, what you just said about Lynch
syndrome, there are opportunities for screening.
We use ultrasound, we use blood tests.
We watch very closely.
But then, just like with Lynch syndrome, when you
hit a certain age, if you're completed with childbearing,
there are opportunities for risk-reducing surgeries.
And the standard risk reducing surgery for ovarian, and
peritoneal and fallopian tube cancer is actually removal of
the ovaries and fallopian tubes.
Although, there's some really exciting research going on
looking at maybe if we could just take out the fallopian
tube, which may be kind of the worst actor of the three.
And so, I think understanding your family history
that your symptoms, and what you're at risk for is really
important because, you know, here at MD Anderson, we have
some really awesome high-risk screening clinics where you
don't have to worry. You're plugged into the clinic, and
they will walk you through the process of the types of
testing that you need, and also, you know, the types of
interventions that might be appropriate for you to reduce
your cancer risk. So, I think it's really important to
know all these things that we just talked about so that you
can identify your own risk and potentially
get involved.
Yeah, I think the only thing I would add to that
is for people listening and they're thinking, "Oh, my mom
had this and my dad had that." And, you know, I think
that's our responsibility as physicians to help you
understand your family history.
So, I think the most important thing is that you reach out
and you talk to your doctor, whether it's your, you know,
primary care doctor for your annual visit, your
gynecologist to sort of advocate for yourself.
I think you mentioned, kind of, ovarian cancer having
subtle symptoms. And I think it's kind of the same thing.
Like, you have a responsibility to tell your doctor, I'm
having A, B and C.
Because the symptoms are so common, they'll be like, "Oh,
it's probably GI, we might send you for a colonoscopy." We
see this all the time.
And then, people are like, "OK," but they continue to have
symptoms, but they don't go back.
And so, I always tell people, you are your biggest
advocate. So, if something isn't right and something's
changed, go to your doctor.
If they say everything's OK and it's persistent, go to your
doctor and keep going until they do something about it.
And I think talking to them about your family history and
asking questions is also part of advocating for yourself.
Yeah, and I think if you are identified to have, either
to be at risk for a gynecologic malignancy, or
even if you have a gynecologic malignancy, I think the next
step is going to a specialist, right?
And I think that we can't say this enough, there's been
data across all of the different gynecologic cancers,
cervical cancer, uterine cancer, ovarian cancer
that the best outcomes come when you see somebody
in a high-number
setting. They see a lot of this.
They know what to do. They're going to use
guideline-concordant care.
It is essential to see a gynecologic oncologist, and it's
essential to make sure that the person you're seeing sees
more than one of you, right? So, they're experienced.
You're not the first person they've ever seen with this,
that or the other. So, I really do think that advocacy
goes beyond even once we get the diagnosis and making
sure you're in the right place, getting the right
treatment.
Yeah. And I think sometimes we'll hear patients say, "Oh, I
went to my doctor and they said, 'Oh, well, we'll just take
it out and see what it is. And then we'll send you.'" I
think particularly if you're a postmenopausal,
if you have ovarian masses, there's an opportunity
for us as oncologists to do everything
at the same surgery. So, for example, if you go and you
have just your ovaries taken out, oh, and then it's cancer,
then you may have to go back to surgery for the staging
procedure or additional information.
One of the benefits of coming somewhere like here or seeing
a gyn oncologist is we can do that evaluation while
you're under anesthesia and asleep, get
that information and then action on it at the same time.
So, it often helps expedite care.
And I think that's why studies have shown that patients
have better outcomes.
Yeah. And I think even if you're getting a risk-reducing
surgery, it can be really important where you get that
done, right? Because you and I both know that when we take
out ovaries, or fallopian tubes, or a uterus in
patients that are at a hereditary risk for cancer,
they need to be processed in a very specific way
and assessed in a very specific way so that we don't miss
any early evidence of pre-cancer or
microinvasive, tiny, tiny bits of cancer that would need
to be treated and, if missed, could lead to
a subsequent recurrence of disease or, you know, inadequate
care. And so, I think where you go first really matters
and making sure that you're getting that appropriate,
guideline-concordant care in the hands of an expert
is really going to be important.
Wow, we covered a lot of ground today.
So, one more thing I thought of that often comes
up when we, kind of, talk about screening and things like
that is patients say, "Well, isn't CA-125
a marker for ovarian cancer?
Can't I just get that?
And isn't that going to help me screen for ovarian cancer?"
So, what do you say when people ask you that.
Yeah, I mean it's, I wish it was, right?
So, I think the issue has been when we've looked at studies
where we just get CA-125s on everybody, we end
up doing too much.
We end up taking people to surgery, having worse outcomes,
having issues happen, and we don't actually find
a higher number of cancers.
So, it doesn't work the way we would like.
And I would say there's a lot of really smart people doing
really great work, trying to find other markers or
algorithms that will help us identify people
that have early ovarian cancer or are at risk, but
at this point, we do not recommend doing CA-125 on
everybody.
Awesome. Well, it's been so great sitting down with you.
We work together, but we never sit down together and talk.
So, thank you so much for joining us today for this
enlightening conversation.
And thank you for tuning in today.
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