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= Gynecological Oncology = Gynecological oncology is a medical sub-specialty under the branch of Obstetrics and Gynecology, involving cancers of the female reproductive organs. It is a surgical specialty and requires additional training after registering as an Obstetrician/Gynecologist. Gynecological oncologists typically screen and diagnose tumors under six main categories, cervical, uterine/endometrial, ovarian, vulvar, vaginal and fallopian cancers. Treatments are usually invasive surgeries and may include partial or whole removal of the reproductive organs because, aside from cervical cancers, none of the other gynecological tumors are able to be prevented through screenings in the precancerous stage and are often metastasized before detection is possible.

Gynecological Oncology, a relatively new medical field, emerged in 1969, when the American Board of Obstetrics and Gynecologists recognized its need, however gynecological oncology societies had been formed much prior, focusing on research of tumors in the reproductive tract of females, gaining recognition across global medical societies. Sub-Specialisation requires, first completing an Obstetrics and Gynecology residency for four years and then applying for an additional 3 years of training in Gynecological Oncology followed by assessments, with the oncologists subject to ongoing recertification.

Types of Gynecological Cancers
Gynecological cancers are divided and specialized in under the different organs of the female reproductive tract. These cancers can be categorized into ovarian, vaginal, cervical and uterine cancer. Each category has different methods of detection, rates of survival and appropriate intervention and treatments.

- Ovarian Cancers
For more information see Ovarian Cancer

Ovarian cancer is the tumor which is found in the ovary organ of the female reproductive tract and itself can be divided into certain categories of epithelial ovarian, stromal cell and germ cell ovarian cancers. The most common ovarian cancer is found on the surface of the ovary epithelia but can also stem from the fallopian tube. It also the deadliest form of gynecological cancer and reasons for this trend can be linked to there being no early detection screening methods available to identify epithelial ovarian cancer at a curable stage. If found at a later stage, the epithelial ovarian cancer habituates and becomes chemo-resistant by returning in episodes after remission.

Epithelial cancer occurs in women who have gone through menopause and common symptoms are complains of abdominal pain. Treatments include chemotherapy, anti-angiogenic drugs and platinum-based drugs, the latter two focusing on prolonging death.

The other forms of ovarian cancers are stromal cell and germ cell cancers and only consist of 10 percent of ovarian cancer cases. Germ cell ovarian cancer forms tumors in ovarian eggs, typically affecting only one ovary and is more commonly found in younger women. Stromal cell cancer refers to the production of a cancer cell that produces female hormones, causing hormonal imbalances. Germ cell ovarian cancer is responsive to chemotherapy treatment.

Symptoms typical to ovarian cancers in general will include bloating, pain in the pelvic and abdominal region and feeling full quickly or loss of appetite altogether. The procedure for screening include a rectovaginal examination, CT scan and pelvic ultrasounds. For epithelial ovarian cancer, a blood test will be done to check for elevated CA 125 levels, a common indication of the disease.

- Vaginal Cancers
For more information see Vaginal Cancer

Vaginal is an uncommon gynecological cancer found in squamous cell of the vagina. The malignancies are typical of older female patients and is responsive to treatment when detected in its early stages. However, screening must determine whether the cancer has extended from cervical or vulvar carcinomas through a biopsy. MRI is the most common screening method to detect vaginal cancers. Perhaps the most common screening method for vaginal cancer is a colposcopy, otherwise known as a pap test, analyzing the cervical and vaginal wall under a magnifying lens to identify an abnormality of the organ walls.

- Cervical Cancer
For more information see Cervical Cancer

Cervical cancer, after ovarian cancer, is the most common gynecological cancer in the world. Majority of the tumors, if not all, are caused by infections of human papillomavirus (HPV) and begin in the epithelia on the cervical wall. The HPV infection compromises the membrane of the cervical epithelial membrane in a process called pre-cancer. Cervical cancer occurs when the membrane is invaded at the basement level. Precancer is detectable and is often characterized by recurrent and persistent infections of the cervix. Chemoradiotherapy is the most common treatment for cervical cancers, but is often inaccessible to women in third-world countries who are more susceptical to carcinogenic HPV infections and thus cervical cancers ) . If the cancer is localized and has not spread, surgical removal of the cancers is also considered as a form of treatment. However, similar in nature to epithelial ovarian cancer, cervical cancer can be recurrent and when treating with radiotherapy, specialists are advised to consider the female’s quality of life during recurrent treatment of cervical cancers.

- Uterine/Endometrial Cancer
For more information see Endometrial Cancer

Uterine cancer, more commonly known as endometrial cancer, consists of a tumour formed locally in a woman’s uterus. The cancer is common in developing countries but is usually detected at early-stage whilst still localized to the uterus only. The detection of this particular cancer can be linked to symptoms present early and very obvious. Common symptoms are pelvic bleeding, or vaginal bleeding post-menopause or between periods and pelvic pain.

Uterine cancers commonly form in the uterus wall lining, the endometrium. However, less commonly, they can also form as sarcomas in uterine muscle.

Common precursors to endometrial tumors include a early period or late menopause which increases exposure time of the endometrium to high levels of estrogen. Other factors that increase the risk of uterine cancer are uterus never experiencing pregnancy, postmenopausal women, obesity which is linked to hormonal imbalances.

Preventative treatments of the cancer include avoiding hormone replacements, focusing on estrogen, post menopause. Other preventative treatments include oral contraceptives which reduce exposure to estrogen, and maintain a healthy body weight.

Screening methods for uterine cancer include ultrasounds, either pelvic or transvaginal, endometrial biopsy and hysteroscopy. If cancer is advanced, doctors will use additional screening methods to check for the spreading of the tumour via X-rays, MRIs, CT scans and PET scans, with additional blood tests.

Treatment will vary according to the progression of the cancer. Hysterecomy is a surgical option whilst for more advanced tumours, radiotherapy and chemotherapy are considered options. Additional options will include hormone therapy and immunotherapy which focus on assisting body fight the endometrial tumour.

Screening and Diagnostic Methods
a variety of methods are used by Gynecological Oncologists, to screen for cancersand can be divided under various categories: biochemical, biophysical and physical-radiological methods. Importantly, the methods of screening predominantly used will vary in each country based on their priorities regarding gynecological cancer and geographical mortality rates for the cancers.

- Cervical Cytology
Cervical Cytology, more commonly known as the Pap Test, is an biophysical testing method, primarily for cervical abnormalities. It involves microscopic analysis of a swab of cervical cells, to identify abnormalities of squamous cells as indications of carcinoma. In preparation for the test, women are advised to abstain from intercourse or penetration of any sort, including using tampons, for 24-48 hours to avoid stripping cells and leaving insufficient cells to be exfoliated for the test. Further, usage of creams in the pubic area prior to test has the ability to contaminate results and is also advised against by practitioners.

The test is touted for its low costs and overall has significantly reduced mortality rates related to cervical cancers. However, the method has also been extensively limited due to the demand for qualified pathologists to perform and examine all results in order to reduce inaccurate results. Also, due to the high volume of pap tests conducted, observer fatigue can make is difficult for pathologists to distinguish results. Due to these limitations, countries such as Australia, who previously required women to conduct a Pap test every two years, have made the systematic change to cervical screen tests.

- Visual Inspections
In less developed countries, physical examinations of the vaginal and cervical areas is used as the predominant screening method. This is done through the application of acetic acid on the cervix, which will stain abnormal cervical tissue with a white stain. This method is renound for its efficiency, and is extremely accesible as it can be performed by not only specialists, but nurses, paramedics and other healthcare professionals. In order to visualise the results, the method is conducted with a special Aviscope.

- Colposcopy
For more information see Colposcopy.

Colposcopy is the a visual magnication of of the cervical epithelium. In order to perform the procedure, healthcare workers first stain the cervical area using acetic acid, then insert an optical device to view an abnormal staining patterns. Although, limitations with this method include it's low sensitivity to detecting certain cervical cancers/tumours.

Colposcopists require intense training time and optical devices can be expensive for purchase, however the test itself can be performed quickly and is a relatively simple procedure.

- Biochemical Ovarian Screening
A common method for screening ovarian cancers is the use of biochemical markers.

A common biomarker used in identifying ovarian tumors in CA125, and is present in ovarian epithelium only in the presence of cancerous cells. However, because CA125 levels can be distorted by other gynecological circumstances, such as endometriosis, unidentified miscarriages and molar pregnancies. Thus, it is most effective in post-menopausal women, as many of CA-125 distortions do not apply to them. An abnormal value, and cause of concern, is usually above the 35umg/mL threshold.

- Genetic Screening
With 90% of genetic cancers occurring due to mutation in BRACA genes, women are at higher risk of developing an ovarian cancer if they possess these gene mutations. Thus, as a precautionary measure, genetic screening determines whether a woman should be take extra precautionary screenings regularly, to detect signs of any ovarian malignancies.

-Trans vaginal Ultrasound
Ultrasongraphy can be utilised to measure abnormal increases in ovarian volume, with the thresold for premonpausal women being 20cm3. Due to individual ovarian uniqueness, this method of screening is not accurate for population screening. It is a screening method used in conjunction with other methods, most commonly CA125 marking.

Although, the ultrasound is also used to measure endometrial lining thickness, for endometrial abnormalities.

Treatment
Removal of gynecological tumours requires surgical skills. With majority of cases needing surgery.

Hysterectomy
For more information see hysterectomy

Hysterectomy is a radical surgery, involving the complete removal of the uterine organ from the body. This surgery, will not necessarily mean removal of the ovaries, but outcomes include unable to carry a baby due to the absence of the womb. For pre-menopausal women undergoing this surgery, wishing to have a baby, they must look at other fertility options such as surrogacy.

Trachelectomy
For women with localised cervical cancer, a trachelectomy is an surgical intervention that allows the possibility of carrying a baby in the uterus. A trachelectomy involves the removal of only the cervix, whilst the uterus,ovaries and Fallopian tubes remain untouched.

Limitations of Gynecological Oncology
The most prevalent issue for gynecological oncology is the variance of resource availability, characterized by the divide between third-world and first-world countries, for screening and diagnosis.

This divide is further characterised by the lack of emphasis of surgical skills and adequate training programs for urgical removal of gynocological tumors.

Past this socioeconomic divide, is the scientific limitations of screening methods, unable to adequately identify tumors in early stages for many of the higher mortality forms of gynecological cancers.

References