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Q: What is a gynecologic oncologist?
A: Gynecologic oncologists are sub-specialists who care for
women with cancers of the ovary, uterus, vagina, and vulva. After graduating
from medical school, gynecologic oncologists complete a four-year residency as
OB/GYN physicians. After residency, they complete a three-year fellowship in
gynecologic oncology at one of 34 gynecologic oncology fellowship programs in
the U.S. During this specialized training, fellows learn to perform advanced
pelvic surgery, surgery of the gastrointestinal and urinary tracts, and
chemotherapy administration. They also learn the principles of radiation
therapy. When all training is completed, gynecologic oncologists are board
certified in OB/GYN and gynecologic oncology. When a woman with gynecologic
cancer sees a gynecologic oncologist, all of her treatment – from start to
finish – is carried out by one physician who has extensive training in women’s
cancer care.
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Q: Are there any screening tests for ovarian cancer?
A: Unfortunately, to date, there are no reliable screening
tests for ovarian cancer. However, serum tests are available to follow patients
already diagnosed with ovarian cancer and determine how they respond to
treatment. Some people have studied whether these tests would be good screening
tests for ovarian cancer. The results show conclusively that these serum tests
are not specific enough to be used for ovarian cancer screening. There is a new
technology called proteomics that is currently being studied for ovarian cancer
screening. Unfortunately, this technology won’t be available for widespread
screening for many years.
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Q: How can I manage my nausea while receiving chemotherapy for ovarian
cancer?
A: One of the biggest concerns that patients have while
receiving chemotherapy is that of nausea and vomiting. In the past, this
problem was quite prevalent because of the chemotherapy agents used and lack of
good, anti-nausea medications. Thankfully, many drugs have since been developed
that can eliminate nausea caused by chemotherapy. These drugs are given prior
to infusion of chemotherapy and continue for three to five days following
treatment. Agents that have been the most successful in eliminating nausea are
called three-5-hydroxytryptamine (or 5-HT3) inhibitors. These drugs block
receptors in the brain that control nausea. If nausea continues to be a
problem, other drugs, working in a different manner to control nausea may be
added to the regimen. Fortunately, with current chemotherapy and anti-nausea
drugs, nausea and vomiting are very manageable problems.
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Q: How do you treat ovarian cancer?
A: The first step is to do an appropriate cancer staging
operation, which includes removal of the ovaries and all other involved tissues
to optimally resect the cancer to a minimal amount. A gynecologic oncologist is
best qualified to perform this surgery. For all patients, except those with
very early ovarian cancer, chemotherapy is recommended after surgery. The
cycles are usually three to four weeks apart and are recommended for six to
eight courses. Most prescribe the current gold standard combination
chemotherapy of paclitaxel/carboplatin. At Savannah Gynecologic Oncology, we
offer the opportunity to participate in clinical trials to treat ovarian
cancer. These trials are conducted through the national Gynecologic Oncology
Group. In selected cases of recurrence, such as tumor isolated to certain
nodes, radiation may be suggested. Finally, if large recurrences are seen on
imaging studies, a “second look” operation may be offered to remove the
affected areas.
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Q: How often should women have Pap tests?
A: In the United States, about 5,600 women die each year from
cancer of the cervix. Since the advent of the Pap smear, death rates from
cervical cancer have decreased markedly. If women have routine Pap smears, this
type of cancer is more than 90 percent preventable. Based on this information,
two organizations -- the American Cancer Society (ACS) and American College of
Obstetricians and Gynecologists (ACOG) – have published guidelines for Pap
smears. Both the ACS and ACOG state that the first Pap smear should occur at
age 21 or three years after a woman begins having sexual intercourse. Both
organizations basically state that every woman should have a yearly Pap test
until age 30, then have the test every two to three years as long as she has
had three consecutive tests with normal results. The ACS recommends
discontinuing at age 70 with three consecutive years of normal results. The
ACOG says no discontinuation based on two caveats: Pap smear screening of women
over age 65 would increase five-year survival by 65 percent. And, gland cell
cancers occur twice as often in women within three years of a normal Pap. Women
should adhere to the recommendations of their gynecologist. Most gynecologists
recommend annual Pap smears.
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Q: If my mother has ovarian cancer, what is my risk of getting ovarian
cancer?
A: Over a woman’s lifetime, the risk of developing epithelial
ovarian cancer is approximately 1.8 percent. Fortunately, only five to seven
percent of patients with epithelial ovarian cancer have an inherited form of
the disease (meaning that most patients have a sporadic, non-inherited form of
the disease). Determining ovarian cancer risk for women depends upon family
histories. For example, if only one first-degree relative has the disease (as
in our example), then a daughter’s risk of developing ovarian cancer at some
time in her life is approximately three to five percent. However, if more than
one first-degree relative (a mother or sister) or multiple family members in
several generations (grandmothers, aunts, cousins, etc.) have either breast or
ovarian cancer, then the risk of developing ovarian cancer might be higher. In
fact, these patients may have an inheritable form of breast/ovarian cancer
caused by mutations in the BRCA 1 and 2 genes. When visiting your physician, it
is important to provide as much family history as you can
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Q: Should I participate in a clinical trial for cervical cancer?
A: Savannah Gynecological Oncology offers two types of clinical
trials for cervical cancer patients. Both trials are offered through an
organization called the Gynecologic Oncology Group (GOG). A phase II trial is
used to evaluate a new drug or treatment, usually for a cancer that has come
back. A phase II trial has the advantage of being new and possibly better than
previously used treatments. However, it also may not be as effective as other
treatments. A phase III trial compares a “gold standard” treatment with a new
treatment (usually one that has been previously evaluated in a phase II study).
Several years ago, articles generated by the GOG established that radiation
plus chemotherapy yielded better survival than radiation alone for advance
cervical cancer. Without such trials, we would not have developed a new gold
standard. The primary advantage of participating in any clinical trial is to
enhance our knowledge of cancer treatment and help us develop future treatments
or cures.
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Q: After treatment for ovarian cancer, how do you follow me for
reoccurrence?
A: Several tools are used to follow patients with ovarian
cancer. The basic principles of medicine include a history and physical exam,
and most important, a pelvic exam. If a tumor marker, such as CA-125, was
elevated prior to the operation and chemotherapy, and falls to normal, this
test is an important tool to detect early recurrence. The CA-125 levels are
elevated in over 80 percent of patients with the most common ovarian cancer.
Most gynecological oncologists initially obtain this blood test at three- to
six-month intervals. Slight elevations of the level are of little concern. We
tell our patients not to be a CA-125 junkie. Occasionally, doctors may order
periodic CT scans or other X-rays to detect recurrences. In addition to CA-125,
other blood tests may be available in the future.
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Q: What are the symptoms and signs of vulvar cancer?
A: Cancer of the vulva (the outer, visible portion of the
female genitals) is rare. It usually occurs in women over 50 years of age, but
15 percent of the time, cases appear in women under age 40. Patients usually
have long term itching or feel a mass or tumor. A painful ulcer may be present.
A persistent wart should arouse suspicion. Often, women delay seeking treatment
for up to 16 months. Women should examine their vulva periodically with a
mirror and talk to their doctor immediately if they suspect a problem. A doctor
can confirm the diagnosis with a biopsy done under local anesthesia.
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Q: What causes persistent feminine itching?
A: Itching of the vulva, or outside of the vagina, can occur
throughout a woman’s lifetime. Often, the itching is the result of a yeast
infection that can affect women at any age. Yeast infections can be treated
with anti-fungal agents. However, if the itching persists, see your
gynecologist for a thorough exam to rule out a pre-cancerous or cancerous
disorder. Many times, women with persistent itching are embarrassed to discus
it in detail with their physician. Instead, they simply ask for creams or
ointments to treat it. However, it’s important to talk to your physician and
have an examination to rule out cancer of the vulva. This is especially
important for older women. Don’t be embarrassed. Your physician is here to help
and he or she doesn’t mind answering your questions.
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Q: What causes vaginal bleeding in a post menopausal patient?
A: Bleeding or spotting six to 12 months after periods have
stopped is abnormal. Possible causes include polyps, use of unopposed estrogen,
use of tamoxifen (a drug given during breast cancer treatment), thinning of the
vagina, or – the most serious cause – cancer of the lining of the uterus. This
endometrial cancer is the fourth most common cancer in women. All
postmenopausal women with bleeding should have an endometrial biopsy to rule
out cancer. Some physicians also use an ultrasound to evaluate the endometrial
thickness. It is not enough to simply have a Pap smear, as this test may miss
as many as 50 percent of all endometrial cancers. The best way to accurately
diagnose endometrial cancer is to perform a D&C (a procedure that removes
tissue from the lining of the uterus for testing), with or without a
hysteroscopy (a procedure that involves inserting a small scope into the uterus
so the doctor can visualize the lining).
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Q: What is a CA-125 test?
A: The CA-125 test is a blood test that checks for a protein
called cancer antigen (CA) 125. The protein is made by some, but not all
ovarian cancers. When a woman is diagnosed with ovarian cancer, physicians may
check to see if she has an elevated CA-125 level prior to surgery and
chemotherapy. By checking the levels throughout treatment, physicians can tell
how well the treatment is working. A normal CA-125 level is less than 35.
Several large studies have shown that checking for CA-125 as an ovarian cancer
screening tool is not useful. The reason is that many other non-cancerous
diseases can also cause abnormal levels of CA-125.
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Q: What is an ovarian cyst?
A: An ovarian cyst can usually be felt during a pelvic
examination or seen on an ultrasound or computerized tomography (CT) scan. In
reproductive age women, most are functional cysts and are associated with
ovulation. However, ovarian cancer can be found in as many as 20 percent of
women with a persistent cyst. Women with persistent ovarian cysts should have
an ultrasound or CT examination. In general, if the cyst is larger than a
tennis ball, solid, and cystic, associated with abdominal fluid, bilateral, or
feels unmovable on pelvic examination, the physician will make a small incision
and use a special scope to examine the cyst more closely. In women past
menopause, a physician may test for elevated levels of a particular type of
serum in the body when deciding whether or not to operate. This serum is called
CA-125. For a very suspicious cyst, patients may be asked to consult with a
gynecologic oncologist.
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Q: What is HPV?
A: Human papilloma virus, or HPV, is the virus responsible for
genital warts on the cervix (the narrow end of the uterus) and vulva (the
outside of the vagina). There are more than 100 types of HPV, some of which can
lead to cervical cancer. The HPV is spread through sexual transmission,
affecting approximately 40 percent of the female population. Most infections do
not result in any symptoms or findings of genital warts, but do result in
abnormal Pap smear results. Fortunately, most infections go away on their own
without any treatment. However, some infections do become chronic, and require
medical treatment of the cervix or vulva.
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Q: What does an abnormal Pap smear mean?
A: In the 1950s, Pap smear testing was introduced to screen or
identify women at risk for cervical cancer (cancer of the cervix or the mouth
of the womb). Over the years, the Pap smear has undergone many upgrades, making
it one of the best screening tools for cancer. An abnormal Pap smear does not
necessarily mean that a woman has cervical cancer. It does, however, suggest
that a woman may have an infection or a pre-cancerous lesion. After an abnormal
Pap smear, a physician may prescribe antibiotics, repeat the Pap smear, or move
directly to a colposcopic evaluation. A colposcopy is a procedure that uses a
magnifying glass to further examine the cervix. The exam helps to direct the
physician if a biopsy of the cervix is necessary. As a screening tool, the Pap
smear has drastically reduced the number of cervical cancer cases by finding
problems in a pre-cancerous stage. This allows doctors to prescribe better
fertility sparing treatments.
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