As per Indian data one in nine persons is likely to face a Cancer diagnosis in their lifetime. A 12.8% increase in Cancer incidence is expected in 2025. The projected cancer burden in India is 29.8 million in 2025. India with its diverse population and health care scenario faces a challenge especially in rural areas to fill the care gap, which is an important determinant of prevention, diagnosis, treatment, supportive care and thus the overall Cancer-Survival Rate. Pooled data have shown a five- year survival rate of 51.7% for Cervical cancer & 66.4% for Breast cancer.
A global study in 2019 has shown that 36.3% of cancers in women are attributable to behavioral, environmental, occupational or metabolic risk factors. Smoking is a leading risk factor. Other risk factors include Alcohol, high basal metabolic index and unsafe sex. As we see a cultural shift, liberalism & Westernism, it is upon us as individuals to inculcate some behavioral and lifestyle choices to make the change a better one.
Some general lifestyle recommendations to reduce risk of cancer include:
● Avoid tobacco - Smoking or Chewing or nasal.
● Be physically active
● Maintain a healthy weight
● Eat a diet rich in fruits, vegetables, and whole grains and low in saturated/trans fat, red meat, and processed meat
● Say no to alcohol
● Protect against sexually transmitted infections; this includes vaccination against human papillomavirus (HPV)
● Use Sun protection and avoid tanning.
● Get regular screening for cervical & breast cancer.
Ovarian and Cervical cancers are the most common gynecological cancers in India & worldwide. Cervical cancer in India is the 2nd most common cancer in women after breast cancer. Gynecological cancers include - cervical, ovarian, endometrial (uterine), vulvar, vaginal andfallopian tube cancer and gestational trophoblastic neoplasia.
Video
Recognising some common symptoms of gynecologic cancers:
⦁ Abnormal vaginal bleeding either post-menopausal or intermenstrual or unusually heavy menstrual cycle, as also vaginal discharge blood tinged or foul smelling is common for most gynecological cancers except vulvar cancer.
⦁ Easy fullness or difficulty in eating, bloating and abdominal or back pain can occur in Ovarian cancer.
⦁ Pelvic pain or pressure can occur in Ovarian or Uterine cancers.
⦁ Frequency & urgency to urinate and / or constipation can be a symptom due to close proximity of the genital organ to the bladder & rectum anatomically.
⦁ Itching, burning, pain or tenderness of vulva. Also changes in its skin color, rash, sores or warts are found in vulvar cancer.
Prevention
Vaccination and screening tests are the frontline aspects of prevention. As Human Papilloma virus (HPV) is a sexually transmitted infection that causes the majority of cervical, vaginal and vulvar cancers, HPV vaccination plays an important role in its prevention.
Table shows the HPV infection attributing to cancer in various areas.
HPV Vaccination Schedule
Given above is the guidance for HPV vaccination. There are different vaccines available Bivalent, Quadrivalent and Nonavalent namely Cervarix, Gardasil 4 and Gardasil 9 respectively, all available in India. They can be used as per the schedule shown in the given table.
Screening Tests - Cervical Cancer
These help detect precancerous changes of cervix, making early detection & treatment possible. The commonly used tests are Cervical cytology (Pap Test) - conventional slide test or liquid based methods. Another is HPV DNA testing. They may be done alone or as Co-testing. Also used in low resource settings like rural India is the Visual Inspection Acetic acid (VIA) test.
The Federation of Obstetrics and Gynecological Societies of India (FOGSI) recommends commencement of screening from age 25yrs in good resource areas otherwise at age 30. Cytology is done every 3 years when done alone. High risk HPV test when done alone as primary test is advised every 5-10 years. In limited resource setting at least twice in a lifetime, ie 35 & 45 yrs. Recommended age to end screening is 65 yrs with 3 consecutive negative cytology results or 2 consecutive negative HPV results in 10yrs. In low resource areas FOGSI recommends either HPV test if available or VIA every 3-5 yrs between ages 30 to 65 yrs.
WHO recommends testing from age 30 to 50 with frequency every 3 to 10 years depending on the test used.
Other risk factors:
Unopposed action of hormone estrogen is the basis of endometrial cancer.
Lynch syndrome is a genetic risk factor for endometrial & ovarian cancers. BRCA 1 & BRCA 2 variants increase risk of mainly breast & also ovarian cancer
Use of Tamoxifen especially in post menopausal women may increase the risk of endometrial cancer.
Chronic anovulation during menopausal transition or in polycystic ovary syndrome (PCOS) may be associated with endometrial hyperplasia and progression to endometrial cancer.
Nulliparity and infertility could thus be risk factors for endometrial cancer. But nulliparity can be protective in Ovarian cancers.
Smoking increases risk of mucinous ovarian cancer.
Obese people have high endogenous estrogen and alterations in insulin resistance thus increasing their risk of endometrial cancer. Also moderate increased risk of ovarian cancer is associated with high BMI.
Early menarche and late menopause increases the risk of endometrial cancer as well as epithelial ovarian cancer.
Age - Below age 20, germ cell ovarian tumors predominate, 30 to 40 yrs borderline ovarian tumors and 50 & above it’s epithelial ovarian cancer. Overall risk increases with age.
A first degree relative with either endometrial cancer or ovarian cancer increases one’s risk.
Protective factors:
Use of oral contraceptive pills decreased risk of endometrial cancer by 30-40% in a large study. Progesterone only contraceptives have an even better protective effect.
Pregnancy has a protective effect, number of pregnancies and also older age at last birth play a role too in endometrial cancer. Also pregnancy & lactation lowers incidence of ovarian cancer
Breastfeeding reduces risk.
Physical activity and diet are beneficial.
With a knowledge of the risk factors, symptoms, screening tests and vaccination schedules it’s imperative for each woman to be proactive in making the lifestyle changes, undergoing regular screening, recognising any untoward symptoms with early medical attention thereby reducing her risk of gynecological cancers.
(Author: Dr. Arwa Mohsin E. Senior Consultant Obstetrician & Gynecologist Fortis Hospital, Richmond Road, Bangalore)
A global study in 2019 has shown that 36.3% of cancers in women are attributable to behavioral, environmental, occupational or metabolic risk factors. Smoking is a leading risk factor. Other risk factors include Alcohol, high basal metabolic index and unsafe sex. As we see a cultural shift, liberalism & Westernism, it is upon us as individuals to inculcate some behavioral and lifestyle choices to make the change a better one.
Some general lifestyle recommendations to reduce risk of cancer include:
● Avoid tobacco - Smoking or Chewing or nasal.
● Be physically active
● Maintain a healthy weight
● Eat a diet rich in fruits, vegetables, and whole grains and low in saturated/trans fat, red meat, and processed meat
● Say no to alcohol
● Protect against sexually transmitted infections; this includes vaccination against human papillomavirus (HPV)
● Use Sun protection and avoid tanning.
● Get regular screening for cervical & breast cancer.
Ovarian and Cervical cancers are the most common gynecological cancers in India & worldwide. Cervical cancer in India is the 2nd most common cancer in women after breast cancer. Gynecological cancers include - cervical, ovarian, endometrial (uterine), vulvar, vaginal andfallopian tube cancer and gestational trophoblastic neoplasia.
Video
Recognising some common symptoms of gynecologic cancers:
⦁ Abnormal vaginal bleeding either post-menopausal or intermenstrual or unusually heavy menstrual cycle, as also vaginal discharge blood tinged or foul smelling is common for most gynecological cancers except vulvar cancer.
⦁ Easy fullness or difficulty in eating, bloating and abdominal or back pain can occur in Ovarian cancer.
⦁ Pelvic pain or pressure can occur in Ovarian or Uterine cancers.
⦁ Frequency & urgency to urinate and / or constipation can be a symptom due to close proximity of the genital organ to the bladder & rectum anatomically.
⦁ Itching, burning, pain or tenderness of vulva. Also changes in its skin color, rash, sores or warts are found in vulvar cancer.
Prevention
Vaccination and screening tests are the frontline aspects of prevention. As Human Papilloma virus (HPV) is a sexually transmitted infection that causes the majority of cervical, vaginal and vulvar cancers, HPV vaccination plays an important role in its prevention.
Table shows the HPV infection attributing to cancer in various areas.
HPV Vaccination Schedule
Given above is the guidance for HPV vaccination. There are different vaccines available Bivalent, Quadrivalent and Nonavalent namely Cervarix, Gardasil 4 and Gardasil 9 respectively, all available in India. They can be used as per the schedule shown in the given table.
Screening Tests - Cervical Cancer
These help detect precancerous changes of cervix, making early detection & treatment possible. The commonly used tests are Cervical cytology (Pap Test) - conventional slide test or liquid based methods. Another is HPV DNA testing. They may be done alone or as Co-testing. Also used in low resource settings like rural India is the Visual Inspection Acetic acid (VIA) test.
The Federation of Obstetrics and Gynecological Societies of India (FOGSI) recommends commencement of screening from age 25yrs in good resource areas otherwise at age 30. Cytology is done every 3 years when done alone. High risk HPV test when done alone as primary test is advised every 5-10 years. In limited resource setting at least twice in a lifetime, ie 35 & 45 yrs. Recommended age to end screening is 65 yrs with 3 consecutive negative cytology results or 2 consecutive negative HPV results in 10yrs. In low resource areas FOGSI recommends either HPV test if available or VIA every 3-5 yrs between ages 30 to 65 yrs.
WHO recommends testing from age 30 to 50 with frequency every 3 to 10 years depending on the test used.
Other risk factors:
Unopposed action of hormone estrogen is the basis of endometrial cancer.
Lynch syndrome is a genetic risk factor for endometrial & ovarian cancers. BRCA 1 & BRCA 2 variants increase risk of mainly breast & also ovarian cancer
Use of Tamoxifen especially in post menopausal women may increase the risk of endometrial cancer.
Chronic anovulation during menopausal transition or in polycystic ovary syndrome (PCOS) may be associated with endometrial hyperplasia and progression to endometrial cancer.
Nulliparity and infertility could thus be risk factors for endometrial cancer. But nulliparity can be protective in Ovarian cancers.
Smoking increases risk of mucinous ovarian cancer.
Obese people have high endogenous estrogen and alterations in insulin resistance thus increasing their risk of endometrial cancer. Also moderate increased risk of ovarian cancer is associated with high BMI.
Early menarche and late menopause increases the risk of endometrial cancer as well as epithelial ovarian cancer.
Age - Below age 20, germ cell ovarian tumors predominate, 30 to 40 yrs borderline ovarian tumors and 50 & above it’s epithelial ovarian cancer. Overall risk increases with age.
A first degree relative with either endometrial cancer or ovarian cancer increases one’s risk.
Protective factors:
Use of oral contraceptive pills decreased risk of endometrial cancer by 30-40% in a large study. Progesterone only contraceptives have an even better protective effect.
Pregnancy has a protective effect, number of pregnancies and also older age at last birth play a role too in endometrial cancer. Also pregnancy & lactation lowers incidence of ovarian cancer
Breastfeeding reduces risk.
Physical activity and diet are beneficial.
With a knowledge of the risk factors, symptoms, screening tests and vaccination schedules it’s imperative for each woman to be proactive in making the lifestyle changes, undergoing regular screening, recognising any untoward symptoms with early medical attention thereby reducing her risk of gynecological cancers.
(Author: Dr. Arwa Mohsin E. Senior Consultant Obstetrician & Gynecologist Fortis Hospital, Richmond Road, Bangalore)
