Gynecologic Cancers Facts for Women in India
By and large, if we see the magnitude of problem as cancer in India is on rising trend and it is occupying more than 35-40% of the chronic illnesses in our country. By year 2025, probably the cancer will surpass the heart problems. And the largest part of cancers in India is the cancers in females. Why cancer in female is so peculiar that are we gender biased? No, it is just because the cancers in females are divided into 2 categories, category #1 is cancers which are confined to the organs in genital system and breast and the cancers in female overall have different biological behaviour. For example, most of Indian females are non-smokers and they have lesser propensity of getting cancers because of smoking and tobacco related problems. If we go for the biological behaviour of such cancers, maybe it could be lung cancer, it could be oral cancers, laryngeal cancers, the predisposition is because of other causes like human papilloma virus. And that differs from majority of corresponding cancers in male where the main cancer causing agent is tobacco or the ingredients of tobacco. That is not the point of discussion today. Today’s discussion is about cancers of breast and cancers in the genital system of females.
The genetic system of females has predominantly 4 cancers – one is cancer of ovary, second the uterine cancer, third is cervical cancer, and fourth category encompasses all other miscellaneous cancers like vaginal cancers, vulvar cancers, and others. If we go chronologically, the breast cancer forms the largest chunk of these. The breast cancer in western countries occur predominantly in 4th and 5th decade, so also it used to be in India, almost a decade and decade and half ago; however, in recent decade, we have seen a paradigm shift in this epidemiology as the Indian cancers in breast have been reported as early as 2nd and 3rd decade as well. Most of our cancers are biologically slightly different than the western cancers, like they are hormone independent or we have one propensity of triple-negative breast cancers that means the cancers who do not show or exhibit the oestrogen-progesterone receptors, such cancers are biologically aggressive and notorious.
What could be the signs and symptoms of breast cancer? It is very important to know because only after knowing these, one could approach an appropriate doctor. The symptoms could be a painless lump in the breast. A lump which is painful is always diagnosed early and treated early and most of the times they are not cancerous but painless lumps are neglected and that is why the patients come at later stages and that is the main reason why Indian cancers are being treated at the higher stages that is stage 2nd, 3rd, 4th. We have to understand when the tumour grows into the ducts of the breast glands, it can produce bleeding from the nipple and areola, it can produce changes on the skin and areola in form of puckering, in form of ulceration or non-healing wound. It could also be apparent that lot of veins are visible over the breast, especially when the tumour has grown in size considerably. Also, there could be some mass palpable in the armpit, which most of the times is a lymph node. Very unfortunate patients can come up with 4th stage when they have immense loss of weight or they have water accumulated in the abdomen that we call as ascites, or in the chest that is called as pleural effusion. And on further evaluation, it is diagnosed that “Oh, there is a small lump in the breast which is cancerous.”
What are the predominant investigations? Investigation number one is for diagnosis, it’s a very simple diagnosis, by mammography and a fine needle aspiration cytology and trucut biopsy. Biopsies and cytologies are investigations that get the cells from the lump and they are sent to the pathologist for further examination and the pathologist gives us a diagnosis of the cancer if it is there and the type of cancer. The trucut biopsy can also give us the status of hormone receptors to anticipate the probable biological behaviour.
The surgeries predominantly are of two types, one in which we conserve the breast after removal of tumour that is called as a breast conservation surgery, which is standard of care these days in early breast cancers, whereas for advanced cancers and in conditions where breast conservation is not feasible then the breast is removed completely that is called as a mastectomy. These days, the standard of care mastectomy is a modified radical mastectomy. In either of the surgeries, the components treated are the breast and the axillary lymph nodes. So the tumour with the adequate amount of breast, adjacent tissue has to be removed, along with all the lymph node that is a fibrofatty tissues from the armpit, they have to be removed. Upon removing these, we come to know the stage of disease and that stage decides whether the patient will need chemotherapy, radiation therapy, hormone therapy, or combination of these all.
Usually, the prognosis that is the outcome that is survival chance depends on the stage, predominantly depends on the stage and there are some minor factors like disease biology depending on the hormone receptor status. If treated early that is in stage 1, the breast cancers can have a 5-year survival in tune of 75-80% and it decreases to a tune of 15-20% in stage 4. It could be even lesser in much advanced cases with high tumour burden.
Now, if we analyze what could be the cause of the cancers in the breast – the cause could be hormonal cause which is in majority of cases, like the increased oestrogen level. The oestrogen is a female sex hormone that is responsible for development/proliferation of the endometrium that is the uterine lining, development of secondary sexual characters, and it plays a pivotal role in pregnancy and the hormonal status in females. The oestrogen like substances are found in so many things that we consume or we come across, like the pesticides, like the aerated drinks that we consume, like the fatty substances that are available in market in form of fast food, that all contains some oestrogen but they are not the biological replica of oestrogen, they are some sort of what we can call bad oestrogens. And these bad oestrogens then produce deleterious changes in the breast glands to produce slowly cancers. So, the first and foremost is the food and water consumption that we have should be free from this pesticides and the junk food have to be avoided.
The second rising cause of breast cancers is obesity, which is an avoidable cause. It’s because the oestrogen or bad oestrogens proliferate into our body in the fat. The fat has a biological capacity of converting normal or outside oestrogens into worse oestrogens, which are responsible for breasts cancers.
Then comes genetic causes, genetic causes like BRCA1 and BRCA2. All of us must have heard about Angelina Jolie who BRCA gene positive and she underwent a prophylactic surgery. Yes, there can be a prophylactic surgery in which the person is predisposed to cancers and likelihood of getting cancer is in tune of more than 90% and such patients, if they are gene positive, can undergo bilateral mastectomy that is removal of both breast. But in this era of advancement in surgery, one need not have the loss-of-image thoughts in our mind because there are better reconstruction facilities available; person can have bilateral mastectomy and bilateral breast reconstruction done at the same time.
If we come to another cancer like cervical cancer, cervical cancer once upon a time was India’s most common cancer and the main cause was the lack of hygiene. We did not know the causes earlier but now it is very evident that it is a human papilloma virus. And it is very important to know that the females who get the cancer in the cervix, initially from the beginning don’t harbour this human papilloma virus, it is always transmitted by a male to a female, so it is very important to vaccinate all these females before the age of marriage that is ideally between 9 to 21, with the vaccine which is recently available.
What could be the signs and symptoms of cervical cancer? One is bleeding from the vagina, bleeding which can occur predominantly during the sexual intercourse and bleeding that is unrelated to the menstrual cycle or bleeding in the postmenopausal that is after having stopped the menstrual cycle. Sometimes, when the disease is advanced, it involves the urinary passage or the rectal passage and can produce urinary and defecation difficulties as well. In advanced stages, it can engulf the ureters that is the two tubes which come from either kidneys and go to the urinary bladder, and then the patient can come with some raised creatinine that is similar picture of a renal failure, but most common presentation is bleeding and white discharge, so these should not be neglected at least and physician opinion has to be sort.
Similar to the breast cancer, the biopsy is the main thing which the diagnosis and the amount of disease, the extent of disease can be ascertained on CT scan or MRI, preferably an MRI.
The treatment remains very simple. The treatments in cervical cancer predominantly are only two, surgery and radiation. Earlier disease, the treatment is surgery. Advanced disease, treatment is radiation. The radiation is always complemented with chemotherapy as a radiation sensitizer agent. These days, the surgery can be done laparoscopically also, so that the early recovery and early return to work is very much possible.
The next cancer is endometrial cancer. Now, what is endometrium? Endometrium is the inner lining of the uterus. This endometrial cancers like breast cancers are hormone responsive, hormone dependent, and probably the hormones are the cause for this breast cancers. They are usually seen in perimenopausal or postmenopausal females and the patient with bleeding, bleeding which is unrelated to the menstrual cycles or the ladies who get the menses means who are premenopausal get excess bleeding during the menses. The ladies who have already attained menopause may get also bleeding which could be a very important sign in detection of endometrial cancer. The diagnosis these days can be done with an endometrial biopsy, which can be office procedure, or a formal dilatation and curettage, very important to keep doing a yearly screening ultrasound of the abdomen, which can detect the increased thickening of the endometrium and that the diagnosis of endometrial cancer.
Again, the mainstay of the treatment is surgery. The surgery involves removal of the uterus, both ovaries with cervix, and the lymph nodes in the abdomen. It also can be done laparoscopically. Unfortunately, radiation has less role, and only in advanced cases in endometrial cancer, when the individual cancer involves more than half of the myometrium that is the muscle coat of the uterus then only the radiation is indicated.
Then comes the ovarian cancer, which is on steep rise in our country, and the symptoms could be very less. Most of the times, ovarian cancers come with advanced stage because the growth in the ovaries do not hinder with the bowel and bladder, so patient does not get bowel and bladder symptoms and so they don’t recognize that there is something wrong going in the abdomen. So, many ladies come with some lump in the abdomen, pain. And sometimes the lumps get torted inside, some torsion occurs, and that produces pain and they go to a doctor. When the diseases are advanced then there can be water accumulation that we call as ascites.
The predominant treatment in case of ovarian cancer is surgery and chemotherapy. It could be combination of two when the ovarian cancers are advanced. In early ovarian cancers, the treatment is removal of both ovaries, uterus with cervix, removal of lymph nodes in the abdomen, removal of the omentum that is a fat laden curtain type of organ in the abdomen, and the philosophy lies in complete excision, whatever and wherever is the point of disease or a sub-centimetre disease also has to be removed because the surgical excision gives the maximum cure chance and whatever is the disease which could be microscopically left is treated then after with chemotherapy.
So these are the common cancers, then come very rare cancers like vaginal cancers and vulvar cancers. The main aetiology in these, as in carcinoma cervix, is a human papilloma virus. And the treatment depends on the size and location. The treatment predominantly is either surgery or radiation complemented with chemotherapy.
So, this is by and large about the cancers in females. And our sincere request for all audience is never underestimate the problem, this is the largest amount of cancers in our society. It is imperative that everyone has to get a good yearly screening with yearly bilateral mammography, need be sonomammography, ultrasound of the abdomen, Pap smear for the screening of cervical cancer.