The evolving role of the Women's Health Specialist in cancer prevention and survivorship.

IMPORTANCE AND OBJECTIVE: This review provides a framework for primary care physicians, internists, family doctors, NP's, PA's, and oncologists caring for women-henceforth referred to as Women's Health Specialists-to identify and screen patients who may be at high risk for inherited cancer syndromes; an intervention referred to as previvorship care. For women who undergo risk-reducing oophorectomy, survivorship care is critical to optimizing quality of life thereafter. In this paper, we review management of the unique survivorship needs and management options for women at risk for or with a cancer diagnosis, highlighting the importance of interdisciplinary care. METHODS: To review the available previvorship and survivorship management strategies, a Pub Med search was performed using keywords "survivorship," "genetics," "cancer," "menopause," "hormone therapy," "screening" in addition to review of guidelines, position statements and expert, and committee opinions from the American College of OBGYN, the American Society of Clinical Oncology, The North American Menopause Society, the National Comprehensive Cancer Network , and the American Society for Reproductive Medicine. DISCUSSION AND CONCLUSION: Women's Health Specialists are in a unique position to identify and screen women who may be at risk for inherited cancer syndromes as well as provide necessary survivorship management following transition from their oncologists' care.

Risk-reducing salpingo-oophorectomy in women with a BRCA1 or BRCA2 mutation.

BACKGROUND: Risk-reducing salpingo-oophorectomy is often considered by carriers of BRCA mutations who have completed childbearing. However, there are limited data supporting the efficacy of this approach. We prospectively compared the effect of risk-reducing salpingo-oophorectomy with that of surveillance for ovarian cancer on the incidence of subsequent breast cancer and BRCA-related gynecologic cancers in women with BRCA mutations. METHODS: All women with BRCA1 or BRCA2 mutations identified during a six-year period were offered enrollment in a prospective follow-up study. A total of 170 women 35 years of age or older who had not undergone bilateral oophorectomy chose to undergo either surveillance for ovarian cancer or risk-reducing salpingo-oophorectomy. Follow-up involved an annual questionnaire, telephone contact, and reviews of medical records. The time to cancer in the two groups was compared by Kaplan-Meier analysis and a Cox proportional-hazards model. RESULTS: During a mean follow-up of 24.2 months, breast cancer was diagnosed in 3 of the 98 women who chose risk-reducing salpingo-oophorectomy and peritoneal cancer was diagnosed in 1 woman in this group. Among the 72 women who chose surveillance, breast cancer was diagnosed in 8, ovarian cancer in 4, and peritoneal cancer in 1. The time to breast cancer or BRCA-related gynecologic cancer was longer in the salpingo-oophorectomy group, with a hazard ratio for subsequent breast cancer or BRCA-related gynecologic cancer of 0.25 (95 percent confidence interval, 0.08 to 0.74). CONCLUSIONS: Salpingo-oophorectomy in carriers of BRCA mutations can decrease the risk of breast cancer and BRCA-related gynecologic cancer.

Gynecologic cancer treatment and the impact of cancer-related infertility.

OBJECTIVE: The objective of this study was to empirically assess the emotional and sexual impact of cancer-related infertility in women with a history of gynecologic cancer. METHOD: Women with a history of gynecologic cancer were approached during their gynecologic oncology clinic appointment; they were provided a description of the study and asked to participate. All participants completed a one-time self-report survey. We present data acquired via the following methods: Center for Epidemiologic Studies-Depression Scale (CES-D), Impact of Events Scale (IES), Modified Inventory of Traumatic Grief (M-ITG), Female Sexual Function Index (FSFI), and the Menopausal Symptom Checklist. RESULTS: The study sample consisted of 20 women, ages 27 to 49 years (mean, approximately 40 years), who had undergone treatment for cervical (40%), ovarian (20%), or uterine (40%) cancer. Forty percent of the sample reported depressive symptoms as measured by the CES-D, with 35% of the women experiencing moderate to severe levels of distress as measured by the IES. The women in this sample experienced dissatisfaction with their overall sex lives (67%), pain during vaginal penetration (62%), and low levels of sexual desire (56%). CONCLUSIONS: The preliminary findings of this study indicated that feelings of depression, grief, stress, and sexual dysfunction are being experienced by women with a history of gynecologic cancer who have lost their fertility as a result of their cancer treatment.

Ovarian carcinoma screening in women at intermediate risk: impact on quality of life and need for invasive follow-up.

BACKGROUND: Women with family histories suggestive of an increased risk of ovarian carcinoma who have not had a deleterious BRCA1 or BRCA2 mutation identified are commonly suggested to consider ovarian carcinoma screening with transvaginal ultrasound and/or assessment of CA 125 levels. Limited information is available regarding the impact of this approach on either quality of life (QOL) or need for invasive follow-up in this group of women. METHODS: From November 1999 to October 2002, 184 women at intermediate risk of ovarian carcinoma were enrolled in a prospective study. Participants were screened with twice yearly transvaginal ultrasound and CA 125 assessments. Impact on QOL was measured using the Mental Component Summary (MCS) score of the Medical Outcomes Studies Short Form-36. Need for invasive follow-up was determined by questionnaire and medical record review. RESULTS: In the current study, 135 participants underwent > or = 1 follow-up assessment. During a mean of 19.8 months of follow-up, 12.9% of ultrasounds and 3.8% of CA 125 assessments were abnormal. The authors reported that 38.5% of participants had > or = 1 abnormal ovarian screen that required a short interval follow-up. Because of either abnormal bleeding or ultrasound abnormalities, 24% of participants underwent > or = 1 endometrial sampling. Controlling for a history of breast carcinoma and menopausal status, abnormal ovarian screening results were associated with a decrease in MCS score (P = 0.034), whereas the need for endometrial sampling was not (P = 0.87). CONCLUSIONS: Ovarian carcinoma screening in women at intermediate risk was associated with a substantial rate of abnormal screen results, endometrial sampling, and in women with abnormal ovarian screening findings, a decrease in MCS scores. These findings may have important implications for women considering ovarian carcinoma screening and for the design of future ovarian carcinoma screening trials.

Chemotherapy-induced dyspareunia: a case study of vaginal mucositis and pegylated liposomal doxorubicin injection in advanced stage ovarian carcinoma.

BACKGROUND: Chemotherapy can cause vaginal irritation and mucositis, although rarely reported. CASE: A 62-year-old patient with ovarian cancer reported vaginal burning associated with dyspareunia, which emerged 3-5 days after her initial chemotherapy and persisted throughout her treatment. Her discomfort persisted until she was evaluated by our sexual health service and interventions were implemented. On examination, her vaginal vault was erythematous, with mild signs of vaginal atrophy. Her management schema consisted of the following: avoidance of intercourse 3-5 days after chemotherapy, intravaginal vitamin E suppositories three times per week, intravaginal estrogen tablets (initial course of 14 days followed by twice weekly usage), use of lubricants (Astroglide) during coitus, and counseling. Once interventions were introduced, she subsequently resumed sexual intercourse during the remainder of her chemotherapy treatments. CONCLUSION: Patients with sexual complaints during or following cancer treatment can be treated by their community gynecologists or gynecology oncologists or can be treated through a comprehensive sexual health program with restoration of sexual function.

Brain cancer and sexual health: a case report.

OBJECTIVE: Cancer patients often encounter sexual concerns during the diagnosing, treatment, and recovery phase of their illness. However, the sexual concerns of these patients are often overlooked. Brain cancer patients are no exception to this oversight. METHODS: A case report of a 39-year-old patient with a history of high-grade anaplastic astrocytoma presented to the Sexual Health Program at the Memorial Sloan-Kettering Cancer Center complaining of vaginal discharge and several months of amenorrhea. Although the patient was administered extensive aggressive antineoplastic treatments, her disease rapidly progressed. RESULTS: Despite the patient's terminal illness she continued to have normal sexual thoughts, feelings, and desires; however, she had difficulty discussing these issues with her partner and caregiver, who was her mother. An examination by the sexual medicine gynecologist noted no clinical signs of genital infections; however, there was minimal vaginal atrophy. Her sexual health laboratory evaluation was extensively abnormal. Her treatment consisted of intravaginal non-hormonal moisturizers and vaginal lubricants, counseling, and sexual education. The patient successfully engaged in sexual contact with her partner by the third counseling session. SIGNIFICANCE OF RESULTS: Almost all oncology patients have sexual concerns during or following cancer treatment. These patients should be referred to comprehensive sexual health programs for treatment, if available.

Pre- and postmenopausal high-risk women undergoing screening for ovarian cancer: anxiety, risk perceptions, and quality of life.

OBJECTIVE: Recommendations for women at high risk of ovarian cancer include prophylactic salpingo-oophorectomy (PSO) or screening with transvaginal ultrasonography (TVUS) and CA125 levels. The best strategy for improving survival and maintaining quality of life in high-risk women is not known. Premenopausal women may be more reluctant than postmenopausal women to undergo PSO. However, the risk of false-positive screening results may be more likely in premenopausal women, posing potential psychological risk for those enrolled in high-risk ovarian cancer surveillance programs. We sought to determine whether anxiety, depression, perception of ovarian cancer risk, and false-positive test frequency differed between high-risk premenopausal and postmenopausal women initiating ovarian cancer screening. METHODS: High-risk women aged > or = 30 years enrolling in a TVUS plus CA125 ovarian cancer screening study completed standard QOL (SF-36), cancer-specific anxiety (IES), depression (CES-D), and ovarian cancer risk perception measures. CA125 > 35 and TVUS showing solid or complex cystic ovarian masses were considered abnormal. Abnormal tests were repeated after 4-6 weeks. Persistently abnormal tests prompted a search for malignancy. Tests that normalized on repeat were considered false positive. RESULTS: One hundred forty-seven high-risk women, median age 46 (range, 30-78), 78 premenopausal and 69 postmenopausal, had > or = 1 TVUS/CA125/outcome assessment. Premenopausal women were more likely than postmenopausal women to consider themselves at higher risk of ovarian cancer compared with women their age (P < 0.001) and compared with women with similar family histories (P < 0.001). Mean personal perception of lifetime risk of ovarian cancer among premenopausal women was 37% (range, 0-90%) versus 26% (range, 0-60%) among postmenopausal women (P = 0.02). While general QOL and depression scores were similar, 38% of premenopausal women reported high anxiety versus 27% of postmenopausal women (P = 0.03). Thirty percent of women required repeat CA125 or TVUS after first screening; 10.8% of premenopausal women versus 4.6% of postmenopausal women required repeat CA125; and 23.3% of premenopausal and 20.6% of postmenopausal women required repeat TVUS. One postmenopausal woman with persistently rising CA125 >100 had negative mammography, colonoscopy, and dilation and curettage/bilateral salpingo-oophorectomy. All other abnormal tests normalized on repeat. Two premenopausal women withdrew due to anxiety following false-positive CA125 results. Five women (2 premenopausal, 3 postmenopausal) with normal TVUS/CA125 screening tests elected PSO, with benign findings. CONCLUSION: Premenopausal women perceive their ovarian cancer risk to be higher, report greater ovarian cancer risk-related anxiety, and are more likely to have false-positive screening results than postmenopausal women. Few high-risk women elect PSO in the short term. Knowledge of the frequency of false-positive screening results and psychosocial outcomes is important for high-risk women choosing strategies for managing ovarian cancer risk.