This session defines the various diagnoses classified as gynecological malignancies and address the discreet nuances of each disease, as well as recognition and management of specific side effects associated with individual syndromes. Conventional and targeted therapies are reviewed as well as discussions assisting patients in the selection of integrative approaches to care.
3. Description and Objectives
• Description: This session will define the various diagnoses classified as
gynecologic malignancies and address the discreet nuances of each
disease, as well as recognition and management of specific side effects
associated with individual syndromes. Conventional and targeted
therapies will be reviewed, as well as a discussion assisting patients in the
selection of integrative approaches to care
• Objectives: Upon completion of the session, participants will be able to:
– Describe the significance of the various diseases that encompass the
scope of gynecologic malignancies
– Define the role of clinical and patient navigators through the cancer
care continuum for the gynecologic oncology patient and caregivers
– State the management, guidance, and care of various side effects
associated with gynecologic malignancies and their therapies, as well
as gain understanding of various integrative modalities
3
9. Epithelial Ovarian Cancer
Physical Symptoms
• Abdominal discomfort
• Feeling full after eating small
amount of food; inability to eat a
full meal
• Bloating
• Constipation
• Increasing abdominal size or
waistline
• Pelvic discomfort
• Shortness of breath
• Urinary frequency/urgency
Physical Exam
• Ovarian mass
• Abdominal swelling with fluid wave
• Abdominal mass (no wave)
• Decreased breath sounds at lung
bases (late sign)
• Firmness of umbilicus (navel)
9
10. Treatment of Ovarian Cancer
Surgery
• Removal of the uterus (hysterectomy), both
ovaries and fallopian tubes (bilateral salpingo-
oophorectomy [BSO])
AND/OR
Chemotherapy
• May be given through a vein or into the
peritoneum (abdominal cavity)
10
11. Cervical Cancer:
Anatomy of Exocervix and Endocervix
• Exocervix: part of the cervix next
to the vagina
• Types of cells covering the cervix:
– Squamous
– Glandular
• Endocervix: part of the cervix
closest to the uterus
• Transformation zone: location in
the cervix where the squamous
cells and glandular cells meet
11
12. Classifications of Cervical Cancer
Squamous-cell
• 80% to 90% of cervical cancers
• Develops in the squamous cells that cover the surface of the exocervix
Adenocarcinoma
• Develops in the mucous-producing cells of the endocervix
Adeno-squamous carcinoma
• Features of both squamous-cell and adenocarcinoma
Others: Melanoma, sarcoma, lymphoma (uncommon)
12
13. Cervical Cancer Signs and Symptoms
• Usually shows no symptoms
• Abnormal vaginal bleeding
– Bleeding after intercourse
– Bleeding after menopause
– Bleeding between periods
• Unusual discharge from vagina
• Pain during intercourse
13
15. • Body of uterus has 2 main layers:
– Endometrium
– Myometrium
• Nearly all cancers of the uterus start in the endometrium
15
Endometrial Cancer:
Anatomy
16. Differentiation of Uterine Cancer
• Uterine carcinosarcomas
▫ Stromal carcinoma, leiomyosarcoma
• Adenocarcinoma
• Cervical cancer
16
17. Uterine Cancer Signs & Symptoms
• Unusual vaginal bleeding, spotting, or other
discharge
• Pelvic pain, pain with intercourse
• Weight loss
• Late signs and symptoms: ascites, jaundice,
bowel obstruction
17
18. Diagnosis
• Any signs and symptoms must be reported to
the doctor
• Pelvic exam and transvaginal ultrasound
• Endometrial biopsy, hysteroscopy, D&C
• CA125
18
20. We of the “fairer” sex are unique!
(Just ask us!)
• Are all about planning our day,
and our lives...and the
lives of those we love
• Are not at all happy to have that day, that plan, or that life
interrupted
• Are capable of GREAT drama when confronted with ANYTHING
we do not choose to do or have in our bodies
21. Initial Diagnosis
The gynecologic oncology patient
generally learns her diagnosis postop—or
postprocedure.
ONN introduction must be strong,
supportive, and accepting of whatever behavior
the patient and her caregivers exhibit.
Assurance of a future is critical!
Equally important is the promise
that you will be there helping to
navigate that future.
22. Key Issues – aka, Timing Is
EVERYTHING!
• Patient priorities revolve around survival: GLOBAL and SUDDEN LOSS of
CONTROL
• Understanding is golden key to navigating women through this terrifying
journey
• Approach is as unique as each woman
• Opportunity for ONN to establish presence and supportive partnership
23. A Step-by-Step Approach
(Baby Steps...)
• If possible, visit with the patient in her room
• Ask to sit down with her “a moment” and briefly
identify your role (no standing/sitting on the bed)
• Revisit the patient while in hospital to establish rapport
• Make a postdischarge phone call to identify needs that
surfaced upon returning home
• Commit to meeting the patient at the first treatment, if
possible
24. 24
• Learn as much as possible about
the patient:
• Where does he/she live?
• How far will they travel for treatment?
• Insurance? Copays?
• There can be significant geographic,
economic, linguistic and educational
barriers to oncology care access
• Distance from institution has been shown
to influence many factors
Background and “Baggage”
25. 25
Know your
RESOURCES
• Understanding and acceptance is crucial for the rural patient and family
• ACS Navigator may provide lodging, gas vouchers, free wigs,
travel assistance
• Disparities Navigator can help with financial assistance and
referrals to appropriate agencies
• Social worker has access to many services
• USE YOUR RESOURCES with compassion, respect for human dignity
26. The Non-English–Speaking Patient
• Provision of interpreter
• Maintain eye contact and SIT DOWN
Know your community
Know your resources
Know your referral sources
Know your ancillary services
Know your patient – family-support system
• Respect all cultural differences
• ALWAYS seek that common bond
27. Education
• Keep it simple (think big but start small)
• Meet them "where they are"
• Provide authentic bidirectional communication
• Cancer is largely out of the patient’s control; focus on
support and empowerment
• Understand patients are often intimidated and
overwhelmed when communicating with medical
professionals
• Include caregivers and encourage questions
28. Education (cont'd)
• Assist patients in understanding:
– Symptoms
– Meds – interactions
– Body changes
– Energy-level fluctuations
– Markers/test results
Always solicit feedback from the patient—
do not assume comprehension.
44. 44
Food Is POWER!
• Empowering for patients and caregivers
• Determine baseline of patient’s nutrition
• Discuss benefits of well-balanced meals
• Organic choices if possible
• Discuss snacks – protein + carbohydrates
• Small meals
• Possible use of plastic forks/Pyrex cookware for
metal taste in mouth
• 64 ounces of clear fluid/day – HUGE – provide
rationale
45. Food Factoids…
Cancer Promoters: “Cons”
1. Energy-dense foods
2. Sugary drinks
3. Salty and processed foods
4. Red meats, including processed
meats
5. >1-2 alcoholic drinks
6. Oils: soy/sunflower/corn/trans
fats
7. Omega-6 fatty acids
Cancer Blockers “Pros”
1. Nutrient-dense foods
2. Green tea/pomegranate juice
3. Herbs & spices (tumeric, garlic)
4. Fish, vegetable proteins (lentils,
tofu)
5. Glass of red wine (pinot noir)
6. Oils: olive/canola
7. Omega-3 fatty acids
46. Supplements…
“Loaded Topic”
• Crucial to have patient provide you with list of all
supplements/herbals
• Evaluate supplements versus treatment:
– Radiation therapy (RT) patents do NOT need to supplement
with antioxidents while going through RT
– Patients on blood thinners do NOT need to be on Curcumin
– Patients should not take supplements on the day prior, day of, or day
after chemo
• When possible, supplement with REAL food
47. Quality of Life
Spirituality
• Most patients welcome and benefit
from spiritual care during a health
crisis
• Spirituality and religiosity are well
recognized as factors that affect
patients’ quality of life and overall
satisfaction:
• Less anxiety
• Greater well-being
• Less depression
Utilize and partner with
chaplaincy as an integral
part of the navigation
process.
Patient Support
• ONN can facilitate access to
quality psychosocial care from
diagnosis through continuum
• Ongoing patient-driven support
group offers opportunity for
education and peer-to-peer
psychosocial support
• Ease of access and varying times
facilitates optimal participation
47
48.
49. Role of ONN in
Genetic Counseling
• Assess readiness to accept information about genetic
counseling during adjuvant chemo/RT
• Provide preprinted FAQ sheet
• Empower patients as participants in their future
50. • Maintain availability for dialogue/questions and
“consequences” of testing
• Educate BRCA-positive patients about PARP inhibitor trials and
immunotherapy, which are based on gene mutations
• Educate about drugs based on estrogen receptor–
/progesterone receptor–positivity:
tamoxifen/aromatase inhibitors
51. Treatment Related Sexual
Dysfunction
Chemotherapy
• Fatigue
• Nausea
• Alopecia
• Ovarian failure
• Pain
• Mucositis
• Neuropathy
Radiation
• Vaginal stenosis
• Tissue fibrosis and agglutination
• Ovarian failure
• Vaginal dryness
• Atrophic vaginitis
• Pain and bleeding with intercourse
• Fatigue
51
52. 52
Surgery
• Alteration in appearance/function of
genital structures important to sexual
function
• Radical hysterectomy can shorten length of
vagina
• Lymphedema
• Bilateral oopherectomy triggers dramatic entry
into menopause:
• Vaginal dryness
• Lowered libido
• Hot flashes/mood swings
• Infertility
54. 54
Integrating Sexual Health Assessment
into ONN Practice
Obtain a baseline sexual function assessment
• Female Sexual Function Index (FSFI) or Female
Sexual Dysfunction Questionnaire
• Open-ended questions:
• “Many women have talked to me about
some sexual/female discomfort with
treatment. Have you had any issues?”
55. • Inclusion in decision process
• Honest information
• To be listened to
• Practical help (transportation, medicines, equipment)
• Support/assistance at home
• Privacy respected
• Not to be anonymous
What Family Members/Caregivers
Want…
56. Enhancing Partnerships
Helping Caregivers Build Better Relationships
• For couples: Have a “no-cancer” date night
• Work less
• Simplify and reduce the stress at home—say “No”
• Exercise together
• Be patient with role changes
• Don’t fight over food
• Don’t take anger personally
• If you are depressed, get help
• Choose appropriate coping tools
• TALK it out
57. Survivorship
Long-term side effects of
cancer treatment
– Organ damage: lung,
heart, kidney
– Secondary cancers
– Psychosocial issues:
fertility, financial, PTSD
• As patient nears completion
of treatment, optimistically
navigate them toward
survivorship activities
• Educate them about the
survivorship activities in
your facility
• Introduce them to a
participating survivor
• Reassure them that you will
be available if needed
57
58. • This is true terror for the patient, and everything you have done with their
initial care will provide the basis for this very fragile time—more fragile
with each recurrence
• If the doctor allows, steer the dialogue toward palliative care/chronic
disease scenario
• ALWAYS include approved caregivers in the navigation process
• Provide appropriate referrals
• Work as closely as possible with the mid-levels on the team
• If patient is admitted, enlist supportive hospital services:
pastoral/health-psyche/nutrition/social work
Recurrence!
59. • Gynecologic oncology patients are a unique specialty for a
navigator
• Not a big window for a survivorship interval in many cases
• This is an intense/gestalt affiliation with these patients
• So...go into this with eyes open and a commitment to stay the
course with each patient—they deserve our BEST!
63. Oncology Patient Navigation Program
• Bone Marrow Transplant and Breast Program
• Formalized program began in 2010
• Oncology nurse navigators (ONNS) care across continuum
• Breast
• Melanoma
• Gynecologic
• Thoracic
• Gastrointestinal/
genitourinary
• Disparities Navigator
• American Cancer Society Resource Navigator
64. Gynecologic Oncology Program
7 gynecologic oncologists across 3 practices
• 7 radiation oncologists
• Support from:
• 9 nurse practitioners and 1 physician assistant
• 2 hospitalist nurse practitioners
• 3 clinical coordinators
• 7 genetic counselors
• 2 research coordinators
• Case management
• Biorepository
65. Ovarian Cancer
• Most gynecologic cancers have precancers that may be detected before
the malignant; second most common gynecologic malignancy with
the highest mortality
• Almost 75% of patients present with an advanced stage of disease
• The risk for relapse in advanced-stage disease is as high as 70%
• About 15% of women are diagnosed at a local stage before the disease has
spread to lymph nodes or organs
• There is no effective diagnostic test available (yet)
• The incidence increases with advancing age
(transformation EXCEPT most ovarian cancers)
65
66. Differential Diagnosis: Ovarian Cancer
66
Epithelial
90% of all ovarian cancers
Said to occur most in women around 60 years of age
Stromal (from hormone-secreting cells)
Benign: granulosa cell – generally well-behaved
Serolii-Leydig tumors – somewhat well-behaved
Malignant: granulosa cell tumors – NOT well behaved
Most often occurs in women over the age of 50 years
Not as aggressive; prognosis can be good
Germ-cell tumors
Occur most often in young women
Prognosis may be good with chemotherapy
67. Definitive Diagnosis
• Careful history and physical
• Pelvic ultrasound (level III/IV)
• CT of chest, abdomen, pelvis
• CA 125 (blood test)
• Surgery by gynecologic
oncologist
MUST have tissue for definitive
diagnosis
• CT-guided biopsy
• Surgical removal (resection) or
portion of the tumor removed at
surgery
67
68. Cervical Cancer
• 13,240 estimated new cases in 2018
• 45% of cases diagnosed in a localized stage (before
the cancer has spread to other areas)
• 5-year survival rate estimated at 91.7% for cases
diagnosed in the localized stage
• 5-year survival rate estimated at 56% for cases
diagnosed at a regional stage (disease has spread to
areas near the cervix)
• Most commonly diagnosed in women 35 to 44 years
old
68
69. Cervical Cancer Risks
• HPV infection
• Smoking
• Immunosuppression
▫ HIV/AIDS
▫ Medical immunosuppression: autoimmune disease, organ transplant
• Chlamydia – bacterial infection spread by sexual contact
• Diet low in fruits and vegetables
• Long-term use of oral contraceptives (birth control pills)
• Low income
• Diethylstilbestrol (DES)
• Family risk
69
70. HPV Infection
Risks
• Having sex at a younger age
• Multiple sexual partners
• Uncircumcised men
HPV Infection May Lead To Cancer
• Cervix
• Vulva
• Vagina
• Penis
• Anus
• Mouth
• Throat
Symptoms
• May be no visible signs
70
71. Uterine/Endometrial Cancer
• 63,230 new cases estimated in 2018
• 67% of cases are diagnosed in a localized area (before
spreading to lymph nodes or other organs)
• 5-year survival rate for localized endometrial cancer
is 91%
• 5-year survival rate if diagnosed when cancer spread to
regional lymph nodes is 69%
• Most commonly diagnosed in women ages 45 to 74
71
72. FAQs from patients re genetic counseling:
What is genetic counseling?
• I already have/had ovarian cancer, why do I need genetic counseling?
• What type of tests will the genetic counselor talk to me about?
• What are the benefits of testing?
• If I test positive, will it affect my health insurance coverage?
• I know that I don’t want testing. Do I still need to have genetic testing
if I am positive?
• Who in my family is at risk for inheriting the genetic change that increases
cancer risk?
• What would I do differently if I tested positive?
• I still have more questions. How do I find out more information?
73. Education
Courses
> Site-Specific Cancer Series: Gynecologic Cancers Web
Course
Books
> Clinical Gynecologic Oncology
DeSaia and Creasman
> Atlas of Staging in Gynecological
Cancer
> Contemporary Issues in Women’s
Cancer
Suzanne Lockwood
***Please put our Springer book in the center as a larger image.
My statement with this slide is that we’ve ben able to rely on the first 2 ONS published books and now we have an AONN+ comprehensive textbook that covers all aspects of navigation.
Treatment depends on:
The stage of the cancer
Other factors, such as age, overall health status, desire to have children, etc.
Surgery – Primary treatment
Radiation Therapy
Hormonal Therapy
Chemotherapy
Usually combination “sandwich therapy”
5-year relative survival: 81.5%
Localized: 95.1%
Regional: 67.7%
Distant: 17.5%
A linear accelerator used to create external beam radiation. Either photon beams or electron beams may be produced.
1) Photon beam therapy is suited for deep tumors such as the cervical cancer shown here. Beam energy is measured in million volts (MV).
2) Electron beam therapy is indicated for superficial lesions such as inguinal lymph nodes. Beam energy is measured in million electron volts (MeV).
3) HDR Brachytherapy is a powerful form of internally delivered radiation therapy. In brachytherapy, a radiation source is placed directly into or next to a tumor.
One of the most important advances in gynecologic brachytherapy is the movement from 2-dimmensional to 3-dimmensional planning. This allows us to improve the radiation dose coverage to the tumor while limiting excessive dose to normal tissues. There are multiple studies now demonstrating improved outcomes, for example, for cervical cancer patients treated with image guided brachytherapy compared with older 2-dimmensional techniques. An example of a tandem and ovoid applicator using 2-dimmensional planning with an X-ray on the top and example of a tandem and ovoid applicator on the bottom using CT 3-dimmensional planning.
Left is an actual example of a vaginal cylinder applicator (a 13 channel applicator) and the distribution of radiation dose that was delivered around the vaginal apex (left image). A 3D depiction of the anatomy and distribution of the radiation dose (bladder in yellow, rectum in brown, applicator in purple, radiation dose in red) (right image)
Interstitial refers to brachytherapy treatment where there isn’t a cavity for a radiation applicator to fit into and so a series of small hollow little tubes are placed in and near the target tissue. An example of when this might be used is shown in the following illustrations. In the picture on the left there is an oval uterus narrowing down to the rectangular cervix that has a red cervical cancer and a larger rectangular vagina. Ideally after an initial course of external beam radiation therapy and concurrent chemotherapy this red cervical tumor will shrink and allow for a tandem and ovoid applicator (green figures) to fit into the vaginal fornices and cervix so the appropriate distribution of dose (orange) can be achieved (middle image). Sometimes a lesion does not regress at the end of external beam radiation and then may not allow the tandem and ovoid applicator to properly fit as in the picture on the far right.
Interstitial refers to brachytherapy treatment where there isn’t a cavity for a radiation applicator to fit into and so a series of small hollow little tubes are placed in and near the target tissue. An example of when this might be used is shown in the following illustrations. In the picture on the left there is an oval uterus narrowing down to the rectangular cervix that has a red cervical cancer and a larger rectangular vagina. Ideally after an initial course of external beam radiation therapy and concurrent chemotherapy this red cervical tumor will shrink and allow for a tandem and ovoid applicator (green figures) to fit into the vaginal fornices and cervix so the appropriate distribution of dose (orange) can be achieved (middle image). Sometimes a lesion does not regress at the end of external beam radiation and then may not allow the tandem and ovoid applicator to properly fit as in the picture on the far right.
Interstitial refers to brachytherapy treatment where there isn’t a cavity for a radiation applicator to fit into and so a series of small hollow little tubes are placed in and near the target tissue. An example of when this might be used is shown in the following illustrations. In the picture on the left there is an oval uterus narrowing down to the rectangular cervix that has a red cervical cancer and a larger rectangular vagina. Ideally after an initial course of external beam radiation therapy and concurrent chemotherapy this red cervical tumor will shrink and allow for a tandem and ovoid applicator (green figures) to fit into the vaginal fornices and cervix so the appropriate distribution of dose (orange) can be achieved (middle image). Sometimes a lesion does not regress at the end of external beam radiation and then may not allow the tandem and ovoid applicator to properly fit as in the picture on the far right.
