There are four main treatment options to try to remove or destroy cancer. Surgery aims to remove the growth completely or otherwise as much as is safely possible (debulking). Radiation destroys cells and its effect is more marked on some malignant tissues than healthy tissues. Similarly, the objective of chemotherapy is to use drugs that kill malignant cells selectively. Some tumours are inhibited by hormone therapy. Cancer specialists (oncologists) may recommend additional treatment after surgery to improve cure rates even if there is a high chance that surgery has completely removed the tumour.

A: Surgery

Surgery is increasingly undertaken by those with a special interest in the subject. Similarly, surgery on the breast is usually undertaken by a general surgeon with a corresponding special interest. The surgeon is always balancing the potential benefits of the operation and the risk of complications (surgery risks). Some patients are anxious about surgery for cancer as they fear that the operation can accelerate the disease. There is no evidence that this happens. There are times when the cancer is found to be more advanced at surgery than expected and the outcome is less favourable.

Surgical removal of the tumour is the primary treatment for endometrial cancer, ovary and breast. In the early stages of cervical cancer surgery is the first line of treatment particularly in younger healthy women. Extensive surgery for cancer is termed ‘radical’. A Wertheim’s hysterectomy, employed for the surgical treatment of early cervical cancer, involves removal of lymph glands and tissue on either side of the uterus and it is, therefore, more extensive than the usual abdominal hysterectomy. The pendulum swung initially towards radical surgery but recently back towards less extensive surgery. With early cervical cancer, some specialists are now removing the lymph glands laparoscopically and removing the cervix whilst leaving the uterus and fertility intact. Similarly, removal of the whole breast (mastectomy) is no longer as frequently employed. Removal of the lump (lumpectomy) and dissection of lymph glands has become more popular. Ovarian cancer is an indication for surgical removal of all of the tumour if possible or otherwise as much as possible. There is still some debate as to the advantages of radical surgery for ovarian cancer as complication rates are increased with more aggressive surgery. Beyond the age when fertility is an issue, hysterectomy with removal of both ovaries is usually the objective. In a young woman with tumour confined to one ovary, removal of that ovary alone may be all that is required.

In the majority of cases the surgical objectives for ovarian tumours are straightforward but there are times when there are confounding factors. For example, the patient may be keen to conserve at least one ovary and her uterus but the surgeon may be concerned about leaving undiagnosed malignancy. A frozen section (a representative sample removed at operation and examined microscopically during the operation providing a provisional answer within a few minutes) is only of value in a small number of cases.

A 32 year old lady attended for her initial pregnancy assessment at 12 weeks. This was her second pregnancy. In her first pregnancy her AFP (Q32.25) level was low, at that time indicating further investigation (amniocentesis – obtaining a fluid sample from around the baby) to exclude Down syndrome. That test proved negative and she went on to deliver a healthy baby.

At the first examination in the second pregnancy the uterus seemed to be larger than would have been expected for her dates. The two more likely causes would have been twins or that the pregnancy was more advanced than the dates indicated. An ultrasound examination was re quested and this demonstrated just one baby with a size consistent with the dates. The right ovary was enlarged and our radiologist was suspicious of ovarian malignancy. A blood test was sent for tumour markers and the AFP was extremely high. Now the most likely diagnosis was a yolk sac tumour, which is an extremely rare occurrence. Advice was taken from several experts. At 16 weeks into the pregnancy a laparotomy was performed. The tumour was confined to the right ovary which was removed. It proved to be a malignant teratoma which is even more rare than a yolk sac tumour. The pregnancy continued and serial scans and AFP tests were reassuring. At 38 weeks an elective Caesarean section was performed. A healthy baby was delivered and the opportunity taken to confirm that there was no evidence of tumour. Mother and child have done well and 11 years later there remains no sign of the original tumour returning.

This tumour has almost certainly been cured by surgery alone. Radical surgery, chemotherapy or radiotherapy were never required. Malignant teratomas are highly malignant but in recent years the prognosis has improved as they tend to be sensitive to chemotherapy if required. This case is interesting for a number of reasons not least being that it was detected early because of clinical examination simply to assess early pregnancy.

B: Radiotherapy.

Some malignancies, such as cervical cancer may be particularly sensitive to radiotherapy. There are a variety of radiation sources and the treatment requires careful planning by doctors and physicists specialising in this mode of treatment. Traditionally, special applicators were introduced into the uterus and vagina and radium was inserted into these applicators. They were kept in place for up to 48 hours and during this time the patient was kept still to prevent movement of the applicators. There have been significant advances and radiotherapy is faster, less painful and associated with less complications than even a few years ago. The applicators are introduced under general anaesthetic and the radioactive sources are after loaded to protect staff. The modern sources provide stronger radioactive output so that treatment has been reduced to less than 30 minutes. Pelvic radiotherapy can cause troublesome diarrhoea.

C: Chemotherapy.

Chemotherapy employs cytotoxic (toxic to cells) drugs that interfere with the cell division of malignant cells. There is a fine balance between the maximum dose of these drugs that can be safely given and the risk of damaging healthy tissues. Cytotoxic drugs affect cells that are dividing rapidly. Common side effects, therefore, include anaemia, reduced resistance to infection, ulcers, and hair loss. Some cytotoxic agents are given by mouth although most are given though a vein (intravenously). They may be given over the course of a few days and are often repeated at three or four week intervals. Treatment of ovarian cancer has improved the short and medium term survival. New chemotherapeutic agents are being developed and evaluated by clinical trials. Chemotherapy is particularly effective against ovarian germ cell tumours.

D: Hormones.

Some cancers, particularly endometrial cancer and breast are hormone sensitive. There is evidence that breast cancer outcome is more favourable for some women who are given tamoxifen, which is an anti-oestrogen. Cancer of the uterus seems to be inhibited by progestogens and it is our policy to commence medroxyprogesterone if the diagnosis is suspected at curettage; it is continued for one year.

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Women's Cancer - Gynaecology

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