A questionnaire study on disparity of cervical cancer prevention programs in Asia-Oceania.

BACKGROUND: Despite the introduction of cervical cancer screening and human papillomavirus (HPV) vaccines, the utilization pattern was not standardized. The aim of this study was to elicit the current prevention care in Asia-Oceania. METHODS: An online questionnaire was circulated to different countries/cities in Asia-Oceania. The primary objective was to evaluate the coverage of HPV vaccination and cervical screening programs. The secondary objectives were to study the structures of these programs. Five case scenarios were set to understand how the respondents manage the abnormal screening results. RESULTS: Fourteen respondents from 10 countries/cities had participated. Cervical cancer ranked the first in Myanmar and Nepal. About 10%-15% did not have national vaccination or screening program. The estimated coverage rate for vaccination and screening varied from less than 1% to 70%, which the coverage ran in parallel with the incidence and mortality rates of cervical cancer. All regions approved HPV vaccines, although only four provided free or subsidized programs for nonavalent vaccine. Cervical cytology remained the most common screening tool, and 20%-30% relied heavily on visual inspection using acetic acid. The screening age groups varied in different regions. From the case scenarios, it was noted that some respondents tended to offer more frequent screening tests or colposcopy than recommended by international guidelines. CONCLUSION: This study revealed discrepancy in the practice of cervical cancer prevention in Asia-Oceania especially access to HPV vaccines. There is an urgent need for a global collaboration to eliminate cervical cancer by public education, reforming services, and medical training.

COVID-19 and gynecological cancers: Asia and Oceania Federation of Obstetrics and Gynecology oncology committee opinion.

Since the outbreak of COVID-19, there have already been over 26 million people being infected and it is expected that the pandemic will not end in near future. Not only the daily activities and lifestyles of individuals have been affected, the medical practice has also been modified to cope with this emergency catastrophe. In particular, the cancer services have faced an unprecedented challenge. While the services may have been cut by the national authorities or hospitals due to shortage of manpower and resources, the medical need of cancer patients has increased. Cancer patients who are receiving active treatment may develop various kinds of complications especially immunosuppression from chemotherapy, and they and their carers will need additional protection against COVID-19. Besides, there is also evidence that cancer patients are more prone to deteriorate from COVID-19 if they contract the viral infection. Therefore, it is crucial to establish guidelines so that healthcare providers can triage their resources to take care of the most needed patients, reduce less important hospitalization and visit, and to avoid potential complications from treatment. The Asia and Oceania Federation of Obstetrics and Gynecology (AOFOG) hereby issued this opinion statement on the management of gynecological cancer patients during the COVID-19.

Cervix Cancer Research Network (CCRN): Improving Access to Cervix Cancer Trials on a Global Scale.

Eighty-seven percent of cervix cancer occurs in less-developed regions of the world, and there is up to an 18-fold difference in mortality rate for cervix cancer depending on the region of the world. The Cervix Cancer Research Network (CCRN) was founded through the Gynecologic Cancer InterGroup with the aim of improving access to clinical trials in cervix cancer worldwide, and in so doing improving standards of care. The CCRN recently held its first international educational symposium in Bangkok. Sixty-two participants attended from 16 different countries including Pakistan, India, Bangladesh, Thailand, Malaysia, Singapore, Philippines, Taiwan, China, Vietnam, Korea, Japan, Columbia, Brazil, Canada, and the United States. The focus of this symposium was to evaluate progress, to promote new clinical trials for the CCRN, and to provide education regarding the role of brachytherapy in the treatment of cervical cancer.

Cancer prevention in Asia: resource-stratified guidelines from the Asian Oncology Summit 2013.

With economic growth in Asia, cancer has become increasingly prominent as a major health problem. However, discrepancies in infrastructure, economics, and development exist within and between Asian countries. We assess means of primary and secondary prevention for cervical, breast, colorectal, and hepatocellular cancer, and offer recommendations according to resource levels. Primary prevention by health education, lifestyle modification, and avoidance of risk factors should be made available at all resource levels. When resources allow, human papillomavirus and hepatitis B vaccinations should be given to reduce the risk of cervical and hepatocellular cancer, and genetic testing should be offered to detect increased susceptibility to colorectal and breast cancer. Secondary prevention by effective yet affordable screening for precancerous lesions or by early detection of cancer should be offered, followed by appropriate treatment.

Contraceptive strategies for reducing the risk of reproductive cancers.

Reproductive cancers, encompassing various malignancies like endometrial, ovarian, cervical cancer, and gestational trophoblastic neoplasia, pose a significant global health burden. Understanding their patterns is vital for effective prevention and management. Contraceptives show a protective effect against some of these cancers. This clinical guidance document aims to elucidate the disease burden of reproductive cancers and the evidence supporting contraceptive methods in prevention and management. Regional disparities in incidence and mortality highlight the urgent need for targeted interventions, particularly in low-resource settings. Healthcare providers must weigh individual risk profiles and medical eligibility criteria when discussing contraceptive options. Enhanced health literacy through direct patient education is essential for leveraging low-cost behavioral interventions to mitigate reproductive cancer risks.

The use of HE4 in the prediction of ovarian cancer in Asian women with a pelvic mass.

OBJECTIVE: The purpose of this study was to evaluate the performance of human epididymis protein 4 (HE4) and the Risk of Ovarian Malignancy Algorithm (ROMA) for distinguishing between benign and malignant pelvis masses in Asian women. METHODS: This was a prospective, multicenter (n=6) study with patients from six Asian countries. Patients had a pelvic mass on imaging and were scheduled to undergo surgery. Serum CA125 and HE4 were measured on preoperative samples. CA125, HE4, and ROMA were evaluated for sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS: A total of 414 women with an adnexal mass were evaluated, of which 65 had epithelial ovarian (EOC) cancer, 16 had borderline tumors and 11 had other malignant diseases. Compared to CA125, HE4 had lower sensitivity (56.9% vs 90.8%) and NPV (91.8% vs 97.3%), but improved specificity (96.9% vs 67.1%) and PPV (78.7% vs 35.8%) for differentiating between benign pelvic mass and EOC. ROMA had similar sensitivity (89.2% vs 90.8%) and NPV (97.6% vs 97.3%) as CA125, but showed improved specificity (87.3% vs 67.1%) and PPV (58.6% vs 35.8%). ROMA accurately predicted 87.3% of benign cases as low risk, and 82.6% of stage I/II EOC and 89.2% of all EOC as high risk. CONCLUSION: ROMA showed similar sensitivity as CA125 but improved specificity and PPV, especially in premenopausal women. Using ROMA may help predict if a pelvic mass is benign or malignant and facilitate subsequent management planning.

FIGO statement: Fertility preservation.

Fertility preservation is a growing field in reproductive medicine that may raise ethical questions. Preservation of fertility must be discussed with the patient if gonadotoxic treatment is required, whether in the case of benign or malignant pathology, or in the management of transgender identity. As a result, surgery or chemotherapy that has fewer adverse impacts on fertility should be proposed if this does not alter the prognosis of the disease. If the risk of infertility persists, then fertility cryopreservation should be proposed for children and adults of reproductive age. Sperm, oocytes, and gonadal tissue can be cryopreserved for many years. FIGO wishes to emphasize the importance of fertility preservation in the medical and surgical management of patients, and the importance of a specialized, multidisciplinary approach.

Experiences in the prevention and screening of cervical cancer within Thailand.

Cervical cancer is the third most common cancer among Thai women, after breast and colon cancer, with an age-standardized incidence rate (ASR) of 11.7/100 000 women each year, as of 2015. Over decades, comprehensive national cervical cancer screening programs, research, and the HPV vaccination policy have gradually helped decrease the incidence of cervical cancer in Thailand. In 2017, the Thai Ministry of Public Health signed a memorandum of understanding with the Royal Thai College of Obstetricians and Gynecologists to eliminate invasive cervical cancer from Thailand. This is a tremendous challenge for Thailand as a whole. The present paper reviews and discusses the experiences in the prevention and screening of cervical cancer in Thailand.

Worldwide initiatives to eliminate cervical cancer.

In 2020, more than 600 000 women were diagnosed with cervical cancer and 342 000 women died worldwide. Without comprehensive control, rates of cervical cancer incidence and mortality are expected to worsen. In 2020, the World Health Organization adopted the global strategy to eliminate cervical cancer to the threshold of four cases per 100 000 women within the 21st century, using a triple pillar intervention strategy comprising 90% of girls fully vaccinated by the age of 15 years, 70% of women screened by the age of 35 years and again by 45 years, and 90% of women with precancer treated and 90% of women with invasive cancer managed. In countries with high cervical cancer incidence, a tremendous effort will be needed to overcome the challenges. This article discusses the efforts in place to accelerate achievement of this ambitious goal.

Perspective and conception of Thai gynecologic oncologists in palliative care.

BACKGROUND: Palliative care evidently increases the quality of life among the patients with advanced cancer. However, there are very few studies on the aspects of the physicians' ideas, conceptions, or the effects of their ideas in palliative care quality, especially in Asian countries. This study aimed to evaluate the conception and perspective on palliative care in Thai gynecologic oncologists. METHODS: The online survey was distributed to all certificated Thai gynecologic oncologists. The survey could be accessed via working email address, hyperlink, or QR code during May 2020 and January 2021. A 5-point Likert scale captured the perspectives and concepts of palliative care. The association between respondents' characteristics and their choices of content in palliative care, together with their decision making in specified clinical scenarios was analyzed. RESULTS: A total of 207 completed surveys from 320 Thai gynecologic oncologists were received (64.69% participation rate). They prospected a willingness to give the advices to both patients and their families (85.50%), and strongly agreed to introduce palliative care in any stage of cancer at the time of diagnosis (75.80%). The numbers of their palliative cases per year were 5-20 (57.97%) and the palliative care teams were available in their hospitals. They decided to offer early palliative care and do-not-resuscitate, especially for the elders, or patients with advance stages, or recurrent disease. We found that gynecologic oncologists who previously experienced a palliative care training did not show any difference in decision making in specified clinical scenarios, compared with who did not. CONCLUSIONS: Thai gynecologic oncologists responded to the conceptions and perspectives in palliative care. Their concepts of early and willingness to offer a palliative care especially in the elders, advanced stage, or recurrent patients were proven, regardless of the experience in palliative care training.

FIGO staging for carcinoma of the vulva: 2021 revision.

To revise the FIGO staging for carcinoma of the vulva using a new approach that involves analyses of prospectively collected data. The FIGO Committee for Gynecologic Oncology reviewed the recent literature to gain an insight into the impact of the 2009 vulvar cancer staging revision. The Committee resolved to revise the staging with a goal of simplification and actively collaborated with the United States National Cancer Database to analyze prospectively collected data on carcinoma of the vulva. Many tumor characteristics were collected for all stages of vulvar cancer treated between 2010 and 2017. Statistical analysis was performed with SAS software. Overall survival was estimated based on tumor characteristics. Log-rank and Wilcoxon tests were used to analyze overall survival similarities between and within groups of tumor characteristics. Characteristics with similar survivals were then grouped into the same stages and substages. Kaplan-Meier overall survival curves were generated for the resulting stages and substages. There were 12 063 cases with available data. The resulting new staging for carcinoma of the vulva has two substages in Stage I, no substage in Stage II, three substages in Stage III, and two substages in Stage IV. The Kaplan-Meier overall survival curves showed clear separation between stages and substages. The 2021 vulvar cancer staging is the first from the FIGO Committee for Gynecologic Oncology to be derived from data analyses. This revision has a new definition for depth of invasion, uses the same definition for lymph node metastases utilized in cervical cancer, and allows findings from cross-sectional imaging to be incorporated into vulvar cancer staging. The 2021 FIGO staging for carcinoma of the vulva is data-derived, validated, and much simpler than earlier revisions.

Assessment of Adult Women With Ovarian Masses and Treatment of Epithelial Ovarian Cancer: ASCO Resource-Stratified Guideline.

PURPOSE: To provide expert guidance to clinicians and policymakers in three resource-constrained settings on diagnosis and staging of adult women with ovarian masses and treatment of patients with epithelial ovarian (including fallopian tube and primary peritoneal) cancer. METHODS: A multidisciplinary, multinational ASCO Expert Panel reviewed existing guidelines, conducted a modified ADAPTE process, and conducted a formal consensus process with additional experts. RESULTS: Existing sets of guidelines from eight guideline developers were found and reviewed for resource-constrained settings; adapted recommendations from nine guidelines form the evidence base, informing two rounds of formal consensus; and all recommendations received ≥ 75% agreement. RECOMMENDATIONS: Evaluation of adult symptomatic women in all settings includes symptom assessment, family history, and ultrasound and cancer antigen 125 serum tumor marker levels where feasible. In limited and enhanced settings, additional imaging may be requested. Diagnosis, staging, and/or treatment involves surgery. Presurgical workup of every suspected ovarian cancer requires a metastatic workup. Only trained clinicians with logistical support should perform surgical staging; treatment requires histologic confirmation; surgical goal is staging disease and performing complete cytoreduction to no gross residual disease. In first-line therapy, platinum-based chemotherapy is recommended; in advanced stages, patients may receive neoadjuvant chemotherapy. After neoadjuvant chemotherapy, all patients should be evaluated for interval debulking surgery. Targeted therapy is not recommended in basic or limited settings. Specialized interventions are resource-dependent, for example, laparoscopy, fertility-sparing surgery, genetic testing, and targeted therapy. Multidisciplinary cancer care and palliative care should be offered.Additional information can be found at www.asco.org/resource-stratified-guidelines. It is ASCO's view that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.

Can vaginal misoprostol effectively increase rate of a satisfactory colposcopy? A randomized double-blind placebo-controlled trial.

OBJECTIVE: To evaluate the effectiveness of vaginal misoprostol in overcoming an unsatisfactory colposcopy in the patients who had abnormal cervical cytology and to evaluate side effects of vaginal misoprostol. METHODS: Sixty patients with an unsatisfactory colposcopy during the period of September 2007-November 2008 were recruited and randomly allocated to receive either two tablets of 200 microg misoprostol (400 microg) or two tablets of similar-looking placebo vaginally. Colposcopic re-examination was performed approximately 6 h later. The results and side effects before and 2 weeks after the colposcopic re-examination were recorded. RESULTS: Six out of 30 patients in the misoprostol group (20.0%) had a satisfactory colposcopic re-examination compared with 2 out of 27 patients (7.4%) in the placebo group without statistically significant difference (P = 0.172). Three patients in the placebo group dropped out due to not present at the appointment time. Six out of 30 patients (20.0%) and 1 out of 30 patients (3.3%) in the misoprostol group had side effects before and 2 weeks after the colposcopic re-examination orderly. Twenty-seven patients in the placebo group did not have any side effects before and 2 weeks after the colposcopic re-examination. All side effects occurred were minimal and well tolerated. CONCLUSIONS: Four hundred micrograms of vaginal misoprostol were not proved to be effective in converting an unsatisfactory to a satisfactory colposcopy.

Bone metastasis in cervical cancer patients over a 10-year period.

INTRODUCTION: Cervical cancer is the major cancer burden in developing countries. Bone is the third most common site of distant metastasis after the lungs and liver. Therefore, the aims of this study were to find the incidence and clinical characteristics of bone metastasis in our hospital. PATIENTS AND METHODS: Fifty-one cervical cancer patients with bone metastasis during the period from January 1998 to December 2007 were recruited. All patients' medical records were reviewed and analyzed. RESULTS: Among 4620 cervical cancer patients, there were 51 patients (1.1%) who had bone metastases. Ten patients' medical records were not found; thus, 41 patients were available for evaluation. The median age of the patients was 49 years. International Federation of Gynecology and Obstetrics stage IIB was the most common stage (43.9%). Most patients had squamous cell carcinoma (80.48%) and received radiation therapy alone as their primary treatment (58.53%). The most common presenting symptom was pain (78.04%). Most of the patients had multiple bone lesions and extrapelvic bone metastases. The lumbar spine was the most common site (36.36%). Sixteen patients (39.02%) were treated by palliative radiation therapy. The median overall survival was 23 months. CONCLUSIONS: Bone metastases could be found at all stages. Common sites were the bone beyond the radiation field of their primary treatment. It was found at a median of 16 months after cervical cancer diagnosis. Currently, there are many varieties of treatment that result only in palliation. This group of patients has a poor prognosis.

Management of endometrial cancer in Asia: consensus statement from the Asian Oncology Summit 2009.

Endometrial cancer is one of the gynaecological cancers that carries good overall prognosis because it is often detected at early stages of disease. The International Federation of Gynecology and Obstetrics replaced clinical staging with surgical staging in 1988 and updated the system in 2009. Controversies remain regarding the recommended screening protocol for women with a high risk of endometrial cancer, the role and benefit of retroperitoneal lymph-node dissection, the necessity of ovarian resection, the benefit and type of adjuvant radiation therapy, and the safety of hormone-replacement therapy after treatment. This article reviews the available evidence for optimum management of endometrial cancer and how management strategies can be applied in Asian countries with different levels of health-care resource availability and economic development. An overview of the literature for endometrial-cancer screening, diagnosis, and management is discussed. Consensus statements are formulated on the basis of basic, limited, enhanced, and maximum health-care resource availability, using the framework provided by the Breast Health Global Initiative.

A prognostic study of patients with cervical cancer and HIV/AIDS in Bangkok, Thailand.

Cervical cancer is one of the most common cancers of women. In Thailand, the incidence and death rate of cervical cancer are 18.1 and 5.7 per 100,000 women, respectively. Disease progresses faster in patients infected with human immunodeficiency virus (HIV) with acquired immune deficiency syndrome (AIDS). However, limited data are available for Thailand. Here we determined the prevalence of HIV/AIDS and identified factors affecting survival. We reviewed medical records of women infected with HIV with cervical cancer treated at Ramathibodi Hospital from 2007 through 2014. Demographic and clinical data were collected upon diagnosis. We used the Kaplan-Meier method and a Cox proportional hazards model to evaluate the association of overall survival (OS) with risk factors. The mean, median and range of ages at diagnosis of the 1,362 subjects were 53.9 years, 53.0 years and 20-94 years, respectively. The prevalence of HIV/AIDS in patients with cervical cancer was 2.3% and 5-year survival was 61.2%. Multivariable analysis revealed that favourable prognostic factors were a civil servant medical benefit plan and higher education. Advanced cervical cancer was a poor prognostic factor. Prognosis of women with stage III and IV cervical cancer was extremely poor (HR = 7.25 (95%CI: 4.39-11.98)) in stage III and HR = 20.57 (95%CI: 11.59-36.53) in stage IV). The 1-, 3-, and 5-year survival rates of patients with (74.2%, 67.6%, and 63.6%, respectively) or without (87.4%, 71.3% and 63.7%, respectively) HIV/AIDS were not significantly different.

Actinomycin d versus methotrexate-folinic acid as the treatment of stage I, low-risk gestational trophoblastic neoplasia: a randomized controlled trial.

This study is to compare the remission and complication rates of actinomycin D (Act-D) and methotrexate-folinic acid (MTX-FA) as single-agent treatments of stage I, low-risk gestational trophoblastic neoplasia (GTN). From 1994 to 2005, all women with International Federation of Gynecology and Obstetrics stage I, low-risk GTN were randomly assigned to received either intravenous Act-D 10 microg/kg per day for 5 days every 2 weeks or intramuscular methotrexate 1 mg/kg per day on days 1, 3, 5, and 7 with intramuscular folinic acid 0.1 mg/kg per day on days 2, 4, 6, and 8 every 2 weeks. Forty-nine women met the eligibility criteria. Age, human chorionic gonadotropin level, and International Federation of Gynecology and Obstetrics score were similar in both treatment groups. Of the 22 women who received Act-D, 2 were lost to follow-up. Among the 27 women who received MTX-FA, 2 were lost to follow-up, and 6 had to switch to Act-D because of the rising levels of liver enzymes. All 20 women (100%) in the Act-D arm achieved remission compared with 14 (73.6%) in 19 women in the MTX-FA arm (P = 0.02). Mucositis and alopecia were reported more frequently in the Act-D group, whereas elevations of liver enzyme levels were more frequent in the MTX-FA group. Actinomycin D seems to be more effective than MTX-FA in the treatment of stage I, low-risk GTN. Larger multicenter randomized controlled trials should be conducted to establish the most appropriate regimen for these patients.

Asian Society of Gynecologic Oncology International Workshop 2018.

The Asian Society of Gynecologic Oncology International Workshop 2018 on gynecologic oncology was held in the Ajou University Hospital, Suwon, Korea on the 24th to 25th August 2018. The workshop was an opportunity for Asian doctors to discuss the latest findings of gynecologic cancer, including cervical, ovarian, and endometrial cancers, as well as the future of fertility-sparing treatments, minimally invasive/radical/debulking surgery, radiotherapy, chemotherapy, targeted therapy, and immunotherapy. Clinical guidelines and position statement of Asian countries were presented by experts. Asian clinical trials for gynecologic cancers were reviewed and experts emphasized the point that original Asian study is beneficial for Asian patients. In Junior session, young gynecologic oncologists presented their latest research on gynecologic cancers.

EGFL7 and RASSF1 promoter hypermethylation in epithelial ovarian cancer.

DNA methylation is one of the epigenetic mechanisms associated with gene expression and plays a key role as in activation and deactivation of oncogenes and tumor suppressor genes, respectively. This study employed DNA methylation array to identify methylated genes which are highly correlated with various phenotypes of epithelial ovarian cancer (EOC) in Thai patients and to quantify promoter CpG-island methylation of candidate genes. Tissues from patients with serous and non-serous EOC showed significantly higher promoter methylation of EGFL7 and RASSF1 compared to benign cases. These results indicate the potential of investigating promoter CpG-island methylation of cancer-associated genes as biomarkers of disease progression and even possibly of early detection.