Online Health Chat with Robert DeBernardo, MD, and Thomas Morrissey, MD
Friday, September 12, 2014
Throughout the month of September, Cleveland Clinic recognizes Gynecologic Cancer Awareness Month. Gynecologic cancers attack a woman’s reproductive organs, including the cervix, uterus, ovaries, Fallopian tubes, vagina and vulva. When you have been diagnosed with a female cancer, seeking care from a gynecologic oncologist before surgery or medical treatment increases your odds of total cure.
Common symptoms of gynecologic cancers are:
- A change in bowel or bladder habits
- A sore in the pelvic area that does not heal
- Unusual vaginal bleeding or discharge
- A thickening or lump that either causes pain or can be seen in the pelvic area
- Pain or pressure in the pelvic area
About the Speakers
Robert DeBernardo, MD, is a gynecologic oncologist in the Department of Gynecologic Oncology and is also the Director of Minimally Invasive Surgery in Cleveland Clinic’s OB/GYN & Women’s Health Institute. He is board-certified in obstetrics and gynecology as well as gynecologic oncology. He received his medical degree from Temple University School of Medicine. His specialty interests include first time and recurrent gynecological cancers, hyperthermic intraoperative peritoneal chemotherapy (HIPEC), endometrial and ovarian cancer, pathogenesis of endometrial cancer, post-op thrombosis, complex laparoscopy and laparoscopic management of gynecologic malignancy.
Thomas Morrissey, MD, is a gynecologic oncologist in the Department of Gynecology at Cleveland Clinic Florida. He is board-certified in obstetrics and gynecology and gynecologic oncology. Dr. Morrissey specializes in the diagnosis and treatment of cancers of the reproductive system in women. His specialty interests include robotic-assisted laparoscopic surgery for cervical, endometrial and ovarian cancers; gestational trophoblastic disease; cervical, vaginal and vulvar dysplasia/ HPV-associated disease; and gynecologic care of patients with breast cancer.
Let’s Chat About Female Cancers
Moderator: Welcome to our chat today with Cleveland Clinic gynecologic oncologists, Robert DeBernardo, MD, in Cleveland and Thomas Morrissey, MD, in Florida. We are thrilled to have both surgeons available to share their knowledge and expertise about gynecologic cancers in women.
SarcoidLady: What are some of the most common things women should pay attention to that could possibly indicate a cancerous or precancerous condition associated with our reproductive organs?
Robert_DeBernardo,_MD: Excellent question. Women should be aware of their bodies. Unfortunately, most of us are taught that we shouldn't look or touch "down there”. I recommend that women should periodically look at their vulva (external genitals), and if they notice something different (itching, painful area), ask their doctors about it. In addition, women should "know their bodies" and if their menstrual cycle changes or bleeding pattern becomes erratic, they should question this. Women who have gone through the menopause should have no bleeding or spotting. If they do, they should seek immediate medical attention to evaluate this. Most often, it will be nothing to worry about; however, it may be something serious.
JmattTX4: Does the occurrence of a cancerous endometrial polyp put the patient at a higher risk for any other types of cancer? Should more conscientious measures be taken to test for colon cancer or other types of cancer?
Robert_DeBernardo,_MD: Many endometrial cancers will arise in a polyp. This in and of itself does not predispose someone for other cancers. However, endometrial cancer is the second most common cancer in LYNCH syndrome (HNPCC) related cancers. This is a genetic condition that is most commonly associated with colon cancer. Here at the Cleveland Clinic, we are now testing all women with endometrial cancer for HNPCC/Lynch and offering them appropriate screening should they be found to have this condition.
Saba: Does having in vitro fertilization (IVF) or any of the fertility drugs put you at a greater risk for GYN cancers?
Robert_DeBernardo,_MD: Excellent question. Our understanding of the association with infertility, infertility drugs and ovarian cancer has evolved. It is not entirely clear if the drugs are causing an effect or if women with infertility are more predisposed to these tumors. While we do see a correlation, it appears that there is an increase in "borderline" ovarian cancers, but probably not the typical ovarian cancer that requires surgery and chemotherapy to treat. Borderline tumors are technically classified as cancer, yet exist in between non-cancers and cancers. We generally remove them surgically, but they have a low likelihood of recurring. We do not give chemo for these tumors, in general.
MsDuPont: I am 62 years old and have been through menopause. For the past year, I have been experiencing bleeding intermittently as if I were still having a period. I never know when I will have this bleeding. It has started as of lately being more frequent. Is this an indication of cancer?
Robert_DeBernardo,_MD: It may be, however I would not panic. There are many other reasons for this as well. I would suggest that you see a gynecologist as soon as possible for an evaluation. The doctor will start by asking you a few questions about the bleeding you have experienced then do an examination and likely recommend an ultrasound to look at the womb (uterus). If the lining of the uterus appears "thickened," the doctor will likely recommend a biopsy or a D&C to determine the cause. This could be a benign polyp, precancerous condition or a cancer. If it should be cancer, most often these are caught early and are entirely curable. Go see your doctor.
SandyQuestions: Where does the Bartholin gland drain from, and if someone has a bad history of CIN3/HSIL plus positive HPV bad strains and has abnormal vaginal bleeding plus a Bartholin gland that fills with blood and must be drained, is this an indication that there's a possible GYN cancer?
Robert_DeBernardo,_MD: The Bartholin gland is responsible for lubricating the vagina. It often can get clogged and then infected requiring incision and drainage. This is unrelated to the CIN. Bartholin glands can rarely become cancerous. I would not worry about this. If the infection recurs, your doctor can excise the gland and rule out cancer.
Carie: I'm post-menopausal and for the last month I have noticed when showering a small (the size of a grain of rice), non-tender bump on my inner labium. It is not getting bigger but is getting firmer. There is no irritation and no difference in color, and I can't SEE anything in the mirror; I only FEEL it. I'm scheduled to see the GYN in two weeks. In the meantime, do you have any thoughts on what this might be?
Thomas_Morrissey,_MD: While you should definitely have this evaluated by your gynecologist at the time of your scheduled visit, I can say that we often see benign problems, such as blocked hair follicles/pimples or sebaceous cysts, that can have the same description. If your gynecologist has any concern when he or she sees it, the doctor will perform a biopsy in the office.
BeKnowledgeable: Would you talk about GARDASIL®? Is there any risk for giving it to young people? Also, what kind of studies have there been regarding the drug?
Thomas_Morrissey,_MD: GARDASIL and CERVARIX® are the two approved vaccines for the prevention of HPV-related diseases in the genital tract, including cervical cancer. Both vaccines protect against the two "high-risk-type" strains of HPV, which are responsible, in part, for the development of 70 percent of cervix cancers. GARDASIL additionally protects against the development of genital and anal warts in males and females. There is much information available online on the American Academy of Pediatrics and American College of OB/GYN websites, as well as the websites for the specific vaccines named above.
In my opinion, there are no significant safety concerns, and I highly recommend that all boys and girls between the ages of 11 and 25 receive this highly effective vaccine. I have three girls myself and they are all receiving their HPV vaccinations.
SandyQuestions: Dr. Morrissey, is there a difference between studies of HPV with the ThinPrep collection method and larger methods like biopsy? Is one more accurate than the other just because of size?
Thomas_Morrissey,_MD: HPV testing and Pap smears done with ThinPrep collection are screening tests. ThinPrep involves swishing the small plastic broom with which we collect Pap smears in a special liquid that is then placed on the microscope slides to be analyzed. The liquid helps separate the cells and can make viewing them under the microscope easier. If a Pap smear is abnormal or an HPV test is positive for "high-risk-type" strains, then colposcopy and biopsies are then done to make the actual diagnosis. Pap smears tell us that there could be a problem; biopsies tell us what the problem actually is.
SandyQuestions: If someone has a diagnosis of CIN3/HSIL plus positive HPV bad strains and then later suddenly develops abnormal vaginal bleeding and consistently does not have elevated FSH or other hormone studies to prove menopause, what kind of follow up is required?
Thomas_Morrissey,_MD: It is difficult to give a definite answer without more information; but, in general, patients with irregular or heavy vaginal bleeding need to be evaluated by their doctors with the evaluation to include at least a pregnancy test, pelvic exam and Pap smear, and then an endometrial biopsy (if appropriate). Any patient with a history of cervical dysplasia is at risk for recurrent dysplasia (precancerous changes) so evaluation is always required.
SandyQuestions: So, if I've had an abnormal Pap plus colposcopy that led to conization surgery and diagnosis of CIN3/HSIL with positive bad HPV, is there any way I can be assured that the abnormal bleeding I have is perimenopause OR a recurrence of bad lesions?
Robert_DeBernardo,_MD: This is a complicated question so I will try to answer this as best I can. First, an abnormal Pap most often should be followed up with a colposcopy. This is a test, as you know, that allows your doctor to visualize the cervix better and identify any abnormal areas. The abnormal area(s) then can be biopsied so we can determine number one if there is a cancer present. In most circumstances, we identify pre-cancer. In this case, CIN3 is the most severe form of pre-cancer. It sounds like your doctor recommended a LEEP or cone. These are procedures that are intended to remove ALL the abnormal tissue. We generally recommend close follow-up with Pap smears to determine if this was successful. Most precancerous lesions of the cervix do not cause bleeding. If you are having continued bleeding following your cone, you should be re-evaluated by your doctor. There are many reasons for this that may not have anything to do with the cervical pre-cancer. If you are done with you family, having a hysterectomy may be your best option.
SandyQuestions: Drs., do you ever see patients that have the serious pre-cancers like mine (CIN3/HSIL) if further problems arise like I've mentioned? I don't have a diagnosis of a cancer, and don't know how one would ever be made and my abnormal bleeding involves more than my vagina right now - so do you (either) ever make an exception and see patients without a cancer diagnosis? My body tells me this is very abnormal - and not sure if I should just give up and perimenopause run its course (even though there's nothing to prove perimenopause).
Robert_DeBernardo,_MD: Yes, we commonly see patients with CIN. I would feel comfortable recommending an evaluation by a Gyn Oncologist.
conbel: Can cervical cancer be detected early? And what are the signs or symptoms?
Thomas_Morrissey,_MD: Cervical cancer is, thankfully, one of the cancers that we can detect and treat early. In fact, we most often detect precancerous changes through Pap smears and HPV testing and are able to treat the precancerous changes and prevent cancer from developing. Regular Pap smears are essential. Symptoms of cervical cancer include heavy or irregular vaginal bleeding, continuous vaginal discharge or drainage, pain during intercourse or a feeling of pressure in the pelvic area. These symptoms do not mean a person has cancer, but should definitely be evaluated by a doctor.
SchoolCounselor: How is cervical cancer treated? And is this something a teenager can get?
Thomas_Morrissey,_MD: Cervical cancer treatment depends on the stage that we detect it. Fortunately, with Pap smears, we are usually able to catch cervical cancers at an early stage when they can be cured with surgery. Tumors that are too large to cure with surgery can be treated with radiation and chemotherapy. Cervical cancer that has spread from the cervix to other areas of the body can be treated with chemotherapy. It is extremely rare for a teenager to develop cervical cancer. Because of this, it is recommended that women do not begin getting Pap smears until age 21.
Lucyintheskies: I had endometrial cancer treated with a complete hysterectomy. It was thought to be Stage 1b. I had an ablation and what was left of the tissue was suspect – a sample was not taken prior to the ablation. Chemo and/or radiation were not recommended. Even though I am approaching my five-year mark, I am concerned that there will be another cancer of a different type. Are GYN cancers precursors for other types?
Thomas_Morrissey,_MD: If a patient is known to have endometrial cancer, the surgical treatment includes removal of the uterus, cervix, Fallopian tubes and ovaries, as well as nearby lymph nodes, so that we can analyze and appraise the tumor to get precise measurements and determine the stage of the caner. We prescribe treatments (or decide no additional treatment is necessary) based on that information. In your case, since the doctors did not know you had cancer until the ablation was already done, they were not able to accurately determine the "stage" information because the ablation likely destroyed much of the tumor and also the lining of the uterus, which is needed to take measurements. The good news in your case is that since most endometrial cancers, if they recur, do so within two years. You are five years from surgery so the chance of the cancer returning is almost zero. Patients with a history of endometrial cancer are at a slightly increased risk of developing colon cancer, and it is important that you undergo colonoscopy screening as recommended. Also, patients with a strong family history of uterine and colon cancer may be recommended to undergo genetic testing for a possible hereditary cancer syndrome. You should discuss this with your doctor if appropriate.
Tillie: Is endometrial cancer the same as uterine cancer?
Robert_DeBernardo,_MD: Endometrial cancer is a subtype of uterine cancer. The uterus is composed of the inside lining (endometrium), the muscle wall (myometrium) and, technically, the cervix. We can see cancers arise in all of these areas. In the United States, endometrial cancer is the most common. Cervical cancer is relatively rare since the Pap smear does such a good job of identifying precancerous lesions. Cancers that arise in the muscle layer of the uterus are called sarcomas and can be very aggressive cancers. Luckily they are quite rare.
Grace: Does having endometriosis (treated with danazol many years ago) put someone at risk for endometrial cancer?
Thomas_Morrissey,_MD: Women with endometriosis are not known to be at increased risk for developing cancer in general, but there have been a few studies showing an increased risk for developing ovarian cancer in women with a history of endometriosis. Two of the less common subtypes of ovarian cancer, clear-cell and endometrioid-type, are more commonly seen in women with prior history of endometriosis. However, the overall risk of developing ovarian cancer remains very small and no specific screening or treatment is recommended other than routine gynecologic evaluations. There is no reported increased risk for developing uterine/endometrial cancer in patients with endometriosis. In addition, there are reports of successful treatment of precancerous changes in the uterus with danazol, so danazol treatment would not be thought to cause any increased risk of endometrial cancer.
lixle: I have a young friend, only 25 years old, in the late stages of ovarian cancer. Isn't the early 20s awfully young for this type of cancer? What could have possibly been the cause?
Robert_DeBernardo,_MD: This is very unusual. Ovarian cancer, at least the type we commonly see, occurs in older women. This type of cancer originates from the epithelium or "skin" of the ovary. These cancers have a propensity to break off and circulate around the abdomen and land on other organs. This explains why so often this cancer is caught in later stages and early detection is so difficult. In her case, given that she is so young, this may represent a cancer that has arisen in a different part of the ovary, such as the "germ cell" – the portion responsible for making eggs. These cancers occur more commonly in young women and behave differently. They can be aggressive and often respond favorably with surgery and chemotherapy.
sara29: How is ovarian cancer detected and can it be cured?
Robert_DeBernardo,_MD: This is a question that we have been struggling with for years with, unfortunately, little success. First of all, there are several studies looking at ultrasound and blood tests to try and identify women with ovarian cancer early, before it has the time to spread. For the most part, we have not been successful. This is due to a number of reasons; first being that normally the ovary is small and deep in the pelvis. It is not easily examined like we can with, say, the breast. Second, ovarian cancer tends to spread to other organs in the pelvis and abdomen relatively early before a large mass grows on the ovary. Finally, the symptoms of ovarian cancer are very common – bloating, nausea, pain, frequent urination, etc., and are often overlooked until late in the game.
syd43: What are the causes and risk factors for ovarian cancer? Are there different types of ovarian cancer?
Robert_DeBernardo,_MD: We are not sure what causes ovarian cancer to be honest. We do know that certain women are at significant risk to develop this disease, including those with a family history of breast or ovarian cancer. Of all the common cancers, ovarian cancer has the highest likelihood of having a genetic cause. BRCA 1 and 2 mutations are associated with a 20 percent to 50 percent lifetime risk of developing this cancer and an even greater likelihood of developing breast cancer! Risks of developing ovarian cancer, aside from genetics, include never having a baby, not breastfeeding, early menses and late menopause, anything that increase the number of ovulatory cycles a woman has. Women on OCP's, who have had their tubes tied, are at less risk, in general. As far as types of ovarian cancer, there are three basic types – epithelial (outer layer of the ovary) (this is what I am referring to above and what most people mean when they say ovarian cancer), germ cell ovarian cancer (from the eggs) and stomal tumors, those that arise from the portion of the ovary that makes hormones.
BETHELMOM: My mother is 89 years old and recently had an MRI for spinal stenosis. The MRI also showed a thickening of her uterine wall. The doctor suggested she see a gynecologist. I made an appointment for her but she refused to go as she does not "feel comfortable seeing that kind of doctor," part of that generation, I guess. My questions are: 1) If there is cancer, at her age would it progress slowly? 2) At her age, is putting her through anything rigorous such as surgery, if needed, really be beneficial, recommended or in her best interest (she had a heart attack and a stent put in 2/23/13 and has emphysema)? 3) What are the symptoms of uterine cancer that I should look for, as she is refusing to go to the gynecologist? 4) Should I insist that she go or at her age let her decide as she most likely would not be a candidate for treatment? Thank you!
Thomas_Morrissey,_MD: This is an issue we are seeing more and more often. Whenever any imaging test is ordered, there is a chance that a completely unrelated abnormality may be found. In your Mom’s case, while I do not have all the details on the MRI report, it sounds like the physicians are concerned about the thickness of the lining of her uterus as seen on MRI. We know that if the lining of the uterus is 4 millimeters or less on ultrasound testing that the chance of cancer is almost zero. However, if the lining is thicker than 4 millimeters, there is a chance that this could be caused by precancerous or cancerous changes, and that is why the appointment with the gynecologist is recommended.
While any decisions regarding further tests should ultimately be up to your Mom, I would recommend that she definitely be seen by a gynecologist at least for an office visit for an exam and to review the MRI report and discuss the specific findings. Further testing with an ultrasound or even a biopsy of the uterine cavity (if recommended) can often can be done right in the office at the time of that visit. Vaginal bleeding is the most common symptom of uterine cancer; however, some patients never have bleeding, and sometimes the only way we are able to diagnose it early in those cases is by noting a thickened endometrial cavity. If uterine cancer is found, there are many treatment options including surgery, radiation and hormone treatments that are tailored to the patient's specific condition and medical history, as well as their desire to undergo treatment.
frankdkit: My mother was diagnosed with uterine cancer at age 70. She had no bleeding or pain, just some incontinence. My GYN said that after 65 I don't need Pap or GYN exams. My mother had a hysterectomy but years later developed and died from colon cancer. This was before colonoscopies. Medicare said colonoscopies are only necessary every 10 years after age 65. With a family history, shouldn't testing be important?
Thomas_Morrissey,_MD: While uterine and colon cancers are fairly common, the presence of both cancers in the same person raises the possibility that there could be a familial cancer syndrome. Your doctor should consider referring you for genetic counseling and consideration of genetic testing for HNPCC (hereditary non polyposis colon cancer) syndrome, which, if present, could increase your risk of colon or uterine cancer. Pap smears are for the detection of cervical cancer and do not test for endometrial cancer. Routine pelvic exams are also not thought to provide early detection of endometrial cancer; however, any vaginal bleeding needs to be immediately evaluated by a doctor with a GYN exam. You should discuss colonoscopy recommendations and whether the Medicare guidelines are appropriate in your case with your gastroenterologist.
ajokn: What is vulvar cancer? I have never heard of it.
Thomas_Morrissey,_MD: Vulvar cancer is cancer that develops in the skin of the vulva. Like other skin cancers, symptoms may include a visible lesion, itching and bleeding. Some vulvar cancers are caused in part by the HPV virus, while others can develop in areas of chronic irritation or in people with other dermatologic problems such as lichen planus or lichen sclerosus. Also, rarely, melanoma can develop in the vulvar area, even though that usually is not an area exposed to the sun. Any new lesion or bleeding area in the vulva should always be evaluated by a gynecologist, and a biopsy should be done when appropriate.
Heidi: Would you discuss hyperthermic intraperitoneal chemotherapy (HIPEC) and if it is being looked at for female cancers?
Robert_DeBernardo,_MD: Hyperthermic intraperitoneal chemotherapy (HIPEC) is a procedure during which we give chemotherapy directly into the abdominal cavity (or lung) at the time of surgery. After removing all disease, we place tubes in the abdomen and circulate chemotherapy for 45 to 90 minutes. The chemo is heated to 42 degrees C to improve its ability to penetrate tissue, and this is thought to increase the effectiveness of the drug. The procedure is being used in some centers such as the Cleveland Clinic. Currently, we are offering this procedure for women with recurrent ovarian/tubal or peritoneal cancer, as well as for other GYN cancers.
JoEllen: My grandmother died from “female cancer” in the 1930s. Granted, at that time that is all it would have been called, but is there any way to guess what type it was – uterine or ovarian? I've had uterine cancer and I am just wondering if it was genetic or a bunch of risk factors.
Thomas_Morrissey,_MD: We are often told that someone's relative had "female cancer." It is impossible to know for sure which type it was. In fact, the doctors back then may not have known themselves, and there were no good treatments available then for any of the possibilities. The most common cancer at that time was likely endometrial or cervical cancer (in the time before Pap smears). If your family has a strong history of others with uterine or colon cancer, your doctor should consider sending you for genetic counseling for possible hereditary cancer syndrome testing.
Moderator: I am sorry to say that our time with Cleveland Clinic Dr. Robert DeBernardo in Cleveland and Dr. Thomas Morrissey in Florida is now over. Thank you for sharing your expertise and time to answer questions today.
Robert_DeBernardo,_MD: Great questions. I enjoyed the interaction.
Thomas_Morrissey,_MD: Thank you very much for joining us.
Moderator: On behalf of Cleveland Clinic, we want to thank you for attending our free online health chat. We hope you found it to be helpful and informative.
To make an appointment with Robert DeBernardo MD, Thomas Morrissey, MD, or any of the other specialists in Cleveland Clinic’s OB/GYN & Women’s Health Institute, please call 216.444.6601, toll-free at 800.223.2273 (extension 46601) or visit us at clevelandclinic.org/obGYN for more information.
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On Cleveland Clinic
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