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  1. 1. Gynecologic OncologyGynecologic Oncology A subspecialty of AgeA subspecialty of Age Samir Fouad KhalafSamir Fouad Khalaf Professor OBGYNProfessor OBGYN Al-Azhar UniversityAl-Azhar University President www.ArabicOBGYN.netPresident www.ArabicOBGYN.net
  2. 2. Origin of the Word "CancerOrigin of the Word "Cancer  The word cancer came from the father of medicine,The word cancer came from the father of medicine, Hippocrates, a Greek physician.Hippocrates, a Greek physician. HippocratesHippocrates used theused the Greek words, carcinos and carcinoma to describeGreek words, carcinos and carcinoma to describe tumors, thus calling cancer "karkinos".tumors, thus calling cancer "karkinos".  The Greek terms actually were words to describe aThe Greek terms actually were words to describe a crab, which Hippocrates thought a tumor resembled.crab, which Hippocrates thought a tumor resembled. Although Hippocrates may have named "Cancer", heAlthough Hippocrates may have named "Cancer", he was certainly not the first to discover the diseasewas certainly not the first to discover the disease
  3. 3. The First Documented Case ofThe First Documented Case of CancerCancer  The world's oldest documented case ofThe world's oldest documented case of cancer hails from ancient Egypt, in 1500cancer hails from ancient Egypt, in 1500 b.c.b.c.  The details were recorded on a papyrus,The details were recorded on a papyrus, documenting 8 cases of tumorsdocumenting 8 cases of tumors occurring on the breast. It was treated byoccurring on the breast. It was treated by cauterization with a hot instrumentcauterization with a hot instrument called "the fire drill".called "the fire drill".  It was also recorded that there was noIt was also recorded that there was no treatment for the disease, only palliativetreatment for the disease, only palliative treatment.treatment.  There is evidence that the ancientThere is evidence that the ancient Egyptians were able to tell the differenceEgyptians were able to tell the difference between malignant and benign tumors.between malignant and benign tumors.  According to inscriptions, surfaceAccording to inscriptions, surface tumors were surgically removed in atumors were surgically removed in a similar manner as they are removedsimilar manner as they are removed today.today.
  4. 4. The Birth of the Pathological AutopsyThe Birth of the Pathological Autopsy  In 1628, the first autopsy was done which paved theIn 1628, the first autopsy was done which paved the way to learning human anatomy and physiology .way to learning human anatomy and physiology .  It wasn't until 1761, that pathological autopsies wereIt wasn't until 1761, that pathological autopsies were performed to research cause of death in ill patientsperformed to research cause of death in ill patients..  In 1980s molecular biology start to influence ourIn 1980s molecular biology start to influence our understanding of the disease processunderstanding of the disease process
  5. 5. Theories on the Causes of CancerTheories on the Causes of Cancer The lymph theory developed in the 17th century, .The lymph theory developed in the 17th century, . It was believed that abnormalities in the lymphaticIt was believed that abnormalities in the lymphatic system was the cause .system was the cause . In late 19th century Rudolph Virchow recognized thatIn late 19th century Rudolph Virchow recognized that cells, even cancerous cells, derived from other cells.cells, even cancerous cells, derived from other cells.
  6. 6. Other theoriesOther theories Other theories surfaced, such as cancer being cause by trauma, parasites, andOther theories surfaced, such as cancer being cause by trauma, parasites, and it was thought that cancer may spread "like a liquid".it was thought that cancer may spread "like a liquid". It was later concluded that cancer spread through malignant cells by GermanIt was later concluded that cancer spread through malignant cells by German surgeon, Karl Thiersch.surgeon, Karl Thiersch. In 1926 a Nobel Prize was wrongfully awarded for the discovery of the causeIn 1926 a Nobel Prize was wrongfully awarded for the discovery of the cause of stomach cancer- a worm.of stomach cancer- a worm. The 20th century saw the greatest progression in cancer research.The 20th century saw the greatest progression in cancer research. Research identifying carcinogens,Research identifying carcinogens, chemotherapychemotherapy,, radiation therapy and betterand better means of diagnosis were discovered.means of diagnosis were discovered. Today, we are able to cure some types of cancer, and research is ongoing.Today, we are able to cure some types of cancer, and research is ongoing. Clinical trialsClinical trials and research studies are out key to finding a cure, or a definitiveand research studies are out key to finding a cure, or a definitive method of prevention.method of prevention.
  7. 7. Gynecologic OncologyGynecologic Oncology A field of medical sub specialization that dealsA field of medical sub specialization that deals with the study and treatment of malignancieswith the study and treatment of malignancies arising in the female reproductive tract, ovary,arising in the female reproductive tract, ovary, cervix, endometrium, vagina, vulva andcervix, endometrium, vagina, vulva and trophoblstic diseasestrophoblstic diseases
  8. 8.  During the second half of the 20During the second half of the 20thth . Century. Century enormous progress has been made in the use ofenormous progress has been made in the use of surgery, radiation therapy, chemotherapy andsurgery, radiation therapy, chemotherapy and other treatment modalities for gynecologicother treatment modalities for gynecologic cancerscancers  Meanwhile, the field of obstetrics andMeanwhile, the field of obstetrics and gynecology grew into such an enormous field,gynecology grew into such an enormous field, clinically and scientifically, that it becameclinically and scientifically, that it became impossible for one doctor to master bothimpossible for one doctor to master both complicated obstetrics, infertility, surgery forcomplicated obstetrics, infertility, surgery for benign conditions and the treatmentbenign conditions and the treatment
  9. 9. Gynecologic OncologyGynecologic Oncology  The field started in 1960s in the USA and the firstThe field started in 1960s in the USA and the first certificate started to be given in 1974certificate started to be given in 1974  The field grows rapidly and many gynecologicThe field grows rapidly and many gynecologic Oncology Societies established.Oncology Societies established.  SGO was founded in 1969SGO was founded in 1969  GOG founded in 1970 sponsored by the NCI and nowGOG founded in 1970 sponsored by the NCI and now have 50 centers and 160 affiliated instituteshave 50 centers and 160 affiliated institutes  IGCS was founded in 1986IGCS was founded in 1986  AGOS May 2006AGOS May 2006
  10. 10. What is gynecologicWhat is gynecologic Oncologist?Oncologist?
  11. 11. Is a specialized obstetrician/gynecologistIs a specialized obstetrician/gynecologist Therefore, gynecologic oncologists have hadTherefore, gynecologic oncologists have had extensive training in providing care for womenextensive training in providing care for women with and without cancerwith and without cancer
  12. 12. Gynecologic oncologists are trained in providingGynecologic oncologists are trained in providing comprehensive, multi-disciplinary carecomprehensive, multi-disciplinary care They are skilled surgical oncologists who also areThey are skilled surgical oncologists who also are trained in administering chemotherapytrained in administering chemotherapy Therefore, they are able to provide an outstandingTherefore, they are able to provide an outstanding degree of continuity of care for their patientsdegree of continuity of care for their patients
  13. 13. Gynecologic oncologist is prepared to provideGynecologic oncologist is prepared to provide supportive services:supportive services: - Pain managementPain management - Management of medical or surgicalManagement of medical or surgical complications from treatment,complications from treatment, - Management of complications of the cancerManagement of complications of the cancer - Hospice referralHospice referral
  14. 14. Gynecologic CancersGynecologic Cancers Gynecologic cancers represent 14% of all solid tumors inGynecologic cancers represent 14% of all solid tumors in women and 11% of deaths from them.women and 11% of deaths from them. Cervical, uterine and ovarian cancer represent 95% ofCervical, uterine and ovarian cancer represent 95% of gynecologic cancers and collectively rank the fourth ingynecologic cancers and collectively rank the fourth in both incidence and mortality among cancers that affectboth incidence and mortality among cancers that affect women in developed countries.women in developed countries. Worldwide, these tumors account for even larger share ofWorldwide, these tumors account for even larger share of cancer mortality in womencancer mortality in women
  15. 15. Cervical CancerCervical Cancer  Worldwide, it is the second most common cancer inWorldwide, it is the second most common cancer in women:women: 493,000 cases of cancer cervix compared to 1.15million493,000 cases of cancer cervix compared to 1.15million cancer breast (2002)cancer breast (2002) In developing countries cancer cervix account of 15% ofIn developing countries cancer cervix account of 15% of all new female cancer compared to 3.5% in developedall new female cancer compared to 3.5% in developed countries due to:countries due to: - Socioeconomic differencesSocioeconomic differences - Behavioral differencesBehavioral differences - Presence of screening programsPresence of screening programs
  16. 16. Number of Cases of Cancer Cervix inNumber of Cases of Cancer Cervix in Egypt, Jordan, USAEgypt, Jordan, USA EgyptEgypt JordanJordan USAUSA TotalTotal Per100,000Per100,000 9696 194194 5,2845,284 AgeAge distributiondistribution 30-4930-49 36.5%36.5% 44.3%44.3% 48.4%48.4% 50-6950-69 52.1%52.1% 41.8%41.8% 30.2%30.2% 70+70+ 9.4%9.4% 11.9%11.9% 15.0%15.0%
  17. 17. Endometrial CarcinomaEndometrial Carcinoma  Worldwide it represents 3.9% of female cancerWorldwide it represents 3.9% of female cancer  It is more common in developed countries :It is more common in developed countries : 18/100,000 in USA & Canada compared to18/100,000 in USA & Canada compared to 6/100,000 in Africa and is related to:6/100,000 in Africa and is related to: - Prolonged high estrogen levelsProlonged high estrogen levels - Few number of childrenFew number of children - Use of HRTUse of HRT
  18. 18. Number of cases of EndometrialNumber of cases of Endometrial Carcinoma in Egypt, Jordan, USACarcinoma in Egypt, Jordan, USA EgyptEgypt 1999-20011999-2001 JordanJordan 1996-20011996-2001 USAUSA 1999-20011999-2001 Total/100,000Total/100,000 124124 405405 14,12914,129 AgeAge distributiondistribution <50<50 33.1%33.1% 26.4%26.4% 15.5%15.5% 50-5950-59 27.4%27.4% 28.9%28.9% 24.4%24.4% 60-7060-70 29.0%29.0% 31.6%31.6% 25.5%25.5% 70+70+ 10.5%10.5% 13.1%13.1% 34.6%34.6%
  19. 19. Ovarian CarcinomaOvarian Carcinoma  Epithelial ovarian carcinoma account for 90% ofEpithelial ovarian carcinoma account for 90% of cases and is the leading cause of death in womencases and is the leading cause of death in women with pelvic malignancieswith pelvic malignancies  The incidence is higher in industrial countries ofThe incidence is higher in industrial countries of the worldthe world  Women who are single and have low parity andWomen who are single and have low parity and a history of breast cancer are at riska history of breast cancer are at risk
  20. 20. Age-standard incidence rate ofAge-standard incidence rate of Ovarian Carcinoma inOvarian Carcinoma in Egypt,Jordan,USAEgypt,Jordan,USA EgyptEgypt 1999-2011999-201 JordanJordan 1996-20011996-2001 USAUSA 1999-20011999-2001 TotalTotal// 100,000100,000 5.45.4 4.64.6 10.010.0 >>5050 2.52.5 2.12.1 3.23.2 50-6950-69 17.717.7 14.114.1 33.533.5 7070++ 14.914.9 17.317.3 52.752.7
  21. 21. Women Knowledge aboutWomen Knowledge about gynecologic Cancergynecologic Cancer
  22. 22. Concerning about developingConcerning about developing gynecologic cancergynecologic cancer 87% concerned about developing cancer87% concerned about developing cancer 52% very concerned52% very concerned 70% concerned about developing ovarian cancer70% concerned about developing ovarian cancer 68% concerned about cervical cancer68% concerned about cervical cancer 66% concerned about uterine cancer66% concerned about uterine cancer
  23. 23. Knowledge about gynecologic cancerKnowledge about gynecologic cancer Despite their concern about developingDespite their concern about developing gynecologic cancergynecologic cancer - 30% feel they are not knowledgeable- 30% feel they are not knowledgeable - 55% feel they are only somewhat knowledgeable- 55% feel they are only somewhat knowledgeable - 14% say they are very knowledgeable- 14% say they are very knowledgeable
  24. 24. Information about Risk FactorsInformation about Risk Factors 54% believe they are at risk in their lifetime54% believe they are at risk in their lifetime 43% do not feel they are at risk43% do not feel they are at risk Women aged 35-44 are most likely to report fellingWomen aged 35-44 are most likely to report felling that they are at riskthat they are at risk
  25. 25. Not aware of any riskNot aware of any risk Hereditary/geneticHereditary/genetic SmokingSmoking Exposure to STDExposure to STD Multiple sex partnersMultiple sex partners ObesityObesity HormonesHormones DietDiet Birth control pillsBirth control pills InfertilityInfertility Unsafe sexUnsafe sex TamoxifenTamoxifen 60%60% 29%29% 15%15% 13%13% 13%13% 6%6% 4%4% 4%4% 3%3% 1%1% 1%1% 0%0%
  26. 26. Factors decreasing riskFactors decreasing risk Not awareNot aware Healthy lifestyle/dietHealthy lifestyle/diet Regular check-upRegular check-up Pap smearPap smear Birth control pillsBirth control pills Lack of family historyLack of family history CondomsCondoms PregnancyPregnancy OthersOthers 72%72% 19%19% 11%11% 11%11% 4%4% 4%4% 3%3% 1%1% 26%26%
  27. 27. Awareness of SymptomsAwareness of Symptoms Do not knowDo not know Abnormal bleedingAbnormal bleeding Pelvic painPelvic pain Vaginal dischargeVaginal discharge BloatingBloating No symptomsNo symptoms Painful intercoursePainful intercourse OthersOthers 47%47% 31%31% 20%20% 9%9% 5%5% 1%1% 4%4% 25%25%
  28. 28. Women are uncertain of what type of specialist theyWomen are uncertain of what type of specialist they would see if they were diagnosed with gynecologicwould see if they were diagnosed with gynecologic cancer:cancer: - 41% say they would need to see a gynecologist41% say they would need to see a gynecologist - 31% would need to see an oncologist31% would need to see an oncologist - 11% mention that they would see gynecologic11% mention that they would see gynecologic oncologistoncologist - 13% do not know what type of specialist they should13% do not know what type of specialist they should seesee
  29. 29. conclusionconclusion  The field of gynecologic Oncology is not wellThe field of gynecologic Oncology is not well understood in many countries and the specialtyunderstood in many countries and the specialty is still far from being established in Arabis still far from being established in Arab countries.countries.  Doctors need to know more about this specialtyDoctors need to know more about this specialty in order to increase patient’s knowledge andin order to increase patient’s knowledge and guide patients to the proper management byguide patients to the proper management by referring them to the Gynecologic oncologistreferring them to the Gynecologic oncologist

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