This publication focuses on the most common gynecologic cancers:
ovarian, uterine/cervix, and endometrium. As with most cancer studies and reviews,
the emphasis is necessarily on early detection modalities, effective treatments,
and prophylaxes. These three distinct cancers affect a significant population
base. It is imperative that data continue to be gathered on total management
of these cancers.
On the prophylaxis realm of ovarian cancer, genetic testing is
critical. The first article, by Thomas Frank, MD, emphasizes the fact that one
out of 10 cases of ovarian cancer derives from an inherited gene mutation. A
majority of hereditary ovarian cancers can be linked to BRCA1 and BRCA2 genes.
Once a woman has been shown to have these genes, she is far more likely to develop
epithelial malignancy of the ovary. Patients with early-onset breast cancer
may carry the mutated gene, which will place them at a significantly increased
risk of developing ovarian cancer. Some clinicians believe all patients with
early-onset breast cancer should be genetically tested to evaluate the risk
for ovarian cancer. There is a dramatic increase in cases of ovarian cancer
with BRCA1 and BRCA2 mutations when women have already been diagnosed with breast
cancer. Thorough history should be obtained from the patient to accurately pinpoint
genetic susceptibility. At the present time, genetic testing remains cost prohibitive
for large segments of the population. However, as insurance carriers are educated
to the impact of this test and as technology advances bring the cost down, more
patients will have access to testing.
At the point of most prevalent detection of ovarian cancer, metastasis
to the abdominal cavity has already occurred. This metastasis is the main reason
for high morbidity/mortality in these women. The development of a vaccine in
the treatment of ovarian cancer has been investigated for many years. As Cheryl
Butts, MS, and Ralph Freedman, MD, PhD, note in their article, the tumor vaccines
currently used stimulate antitumor immune responses and also work with cytokines.
The full efficacy of these vaccines remains to be determined. Clinical trials
are underway and the results have been varied. Currently, no definite recommendations
can be made for practitioners, but this novel concept deserves attention, as
it will ultimately affect patients and physicians in the future.
A number of clinical trials have been conducted with the objective
of ascertaining the efficacy of irradiation alone vs irradiation plus a chemical
modifier in the treatment of women with cervical carcinoma. Perry Grigsby, MD,
reviews the results of some of the trials in the literature. Concurrent with
this review, the NCI released an announcement involving five prospective, randomized
trials demonstrating that irradiation combined with chemical agents is superior
to irradiation alone. Survival improvement was shown in all five studies. These
findings have changed the standard of care in the United States for locally
advanced cervical cancer.
Denis Cavanagh, MD, and colleagues present a review of endometrial
adenocarcinoma, which is the fourth most common cancer in women but has a 5
out of 6 diagnosed survival rate. It is the most common cause of cancer of the
female genital tract. Appropriate staging is critical to the successful management
of this disease. Largely due to the high survival rate and current stage I detectors,
practitioners may undervalue the potential deadliness of adenocarcinoma of the
endometrium. Consulting with a gynecologic oncologist is recommended because,
as evidenced by the study, optimal treatment of early-stage endometrial carcinoma
is not entirely delineated at this juncture. There is hope that a standard optimal
plan will be formulated in the millennium.
The administration of chemotherapy for advanced gastric cancer
is addressed by André Murad, MD, PhD. Gastric cancer, although not a
gynecologic malignancy, is the second most common cancer worldwide. This report
indicates that survival for patients with advanced gastric cancer using chemotherapy
is improved, although slightly. The use of taxanes has shown some success, but
further clinical trial evaluation is obligatory. There is no standard treatment
for post-FAM combination chemotherapy. There is evidence of combined 5-FU and
paclitaxel efficacy for advanced gastric cancer. As with all current and proposed
trials, extensive studies must occur to demonstrate results that merit "standard"
therapy.
I am optimistic that in the new millennium, cancer care will shift
from traditional surgical and chemotherapeutic intervention to molecular and
genetic therapies, through vectors and monoclonal antibodies.
James V. Fiorica, MD