Amanda Wilde (Host): There isn't a screening test for many gynecologic cancers, so it's especially important to know what to watch for. Gynecologic oncologist, Dr. Michael Sundborg, is here with essential information on gynecologic cancers and how to spot the signs.

This is FirstHealth and Wellness podcast from FirstHealth of the Carolinas. I'm Amanda Wilde. And welcome, Dr. Sundborg.

Michael Sundborg, MD: Hello, Amanda.

Host: What are the most common types of gynecologic cancers that you see?

Michael Sundborg, MD: So, the three most common that we see are endometrial cancers, cancer of the lining of the uterus, which is probably the most common gynecologic cancers in the United States. About 3% of women in the United States will be diagnosed with this, and it's the most common cancer that affects women that's gynecologic based.

The second I'd like to talk about is ovarian cancer. It's the most common cause of death for gynecologic cancers. And you brought up a good point, this is one cancer we don't have any screening test for. In the United States, about 1.3% of women will be diagnosed with this every year. There's about 19,710 new cases per year in the United States, and 13,270 women will die from this cancer. And again, that really leads to our absence of any screening tests or being able to determine the risk factors for these patients.

And the third most common cancer in the United States would be cervical cancer. Now, this is a feel-good story because we have ways of detecting this early. This is the one test we do have screening for and that's your Pap test. That simple Pap test has probably saved more women's lives than any doctors in the history of medicine. And we know now that 99.7% is attributed to the human papillomavirus. And luckily for us, we have a vaccine for this virus. It should be given between the ages of 11 and up to 42. It's a preventative vaccine. It's very, very effective. If you go to most countries that are resource short or deprived, meaning that they can't afford doing screening tests like Pap smears, it's the number one cause of cancer death for women in areas such as Sub-Saharan Africa, South America, Asia. But United States, it's a success story. But again, we see about 13,960 new cases per year, and about 4,310 deaths. And what's sad is about most of those deaths could be prevented. If we vaccinated the entire world, just like with smallpox, if we get 70% of the world vaccinated, or even in the United States, we could reduce it by 344,000 deaths or every new diagnosis. So, that's one of the feel-good stories about screening.

Host: So, cervical cancer is a good example of catching cancer early so that you don't get the worst outcome. For the other cancers, what are the symptoms that come with those types of cancers? What should we watch for?

Michael Sundborg, MD: Right. Again, cervical cancer, there are no symptoms, except that the Pap test is allowing us to catch things early before it becomes cancers. Now, endometrial cancer, which is the most common gynecologic cancer in the United States, is usually characterized by some abnormal bleeding. And that's good, because women are pretty smart. They will go see their doctors, as opposed to men like me will wait like two months to go see a doctor. So if you have a postmenopausal patient, a woman over 50, has any sort of bleeding, and it could be spotty, it could be heavy, heavy periods, but the quantity and quality of the bleeding has no correlation whether there's a presence of a cancer, they should be seen by their a primary care doc or provider, and eventually be seen by a woman's healthcare specialist.

And usually, we can do very simple things like in the office, which is a endometrial biopsy that can either pick up a pre-cancer stage or cancer. And the most common reason for this type of cancer is usually being overweight. And the average age that we'll see women is between 60 and 70. And when you're overweight and your postmenopausal and then your ovaries aren't making progesterone because they're not ovulating because you're postmenopausal, you're seeing all this extra estrogen that adipose tissue will convert steroids in your body, so those women are at risk.

Younger women could be at risk. There's a diagnosis called polycystic ovarian syndrome, which is characterized in young women who don't ovulate. They may only have one or two periods a year, but they have very high exposures to estrogen, which can cause them to have endometrial cancer or a pre-cancerous change pre-menopausal. And then, there's about 10-20% of patients may be at risk with something called Lynch syndrome, which is usually associated with colon cancer. But for women, the actual organ that's most at risk is the uterus. So, Lynch syndrome is characterized by multiple members in many generations of the family having colon cancer, ovarian cancer, or uterine cancer, and those patients would be at high risk. And there should be some sort of screening for those patients in that category.

In terms of ovarian cancer, we just don't have any screening, and it's such a subtle cancer that it doesn't present clinically for most women, I would say about 85% of women, until it's advanced stage, stage III or stage IV, with IV being the highest. This is why it's such a deadly cancer. Though we've made dramatic breakthroughs in terms of treating this type of cancer, we haven't really changed the survival rate, though very new promising therapeutic modalities are now available that are changing the face of ovarian cancer. In ovarian cancer, about 20% of patients are at risk for having some sort of syndrome or a genetic predisposition. Angelina Jolie did us a great favor by publicizing the BRCA or BRCA gene. Again, those families are characterized by almost every generation having breast cancer, especially under the age of 50; ovarian cancer, doesn't matter what age; and these are very high risk patients.

Also, ethnicity is important. So, certain ethnic groups like Ashkenazi Jewish patients who are from Eastern Europe. Sometimes they carry what's called a founder effect, and that's an independent risk factor for ovarian cancer. And finally, another independent risk factor is infertility. Patients who have a hard time conceiving can be at risk for developing ovarian cancers.

Host: Now, we talked about the fact there's no formal screening for some of these things, and now we've talked about some things you can look for. But if there is cancer present, are there tests available to diagnose?

Michael Sundborg, MD: Yes. So, some of the subtle signs are, and it's easy to be amiss because they can be confused with rather mundane diagnosis, but things such as early satiety, meaning that when a patient cannot finish her meal, she fills up too quickly, bloating, especially 12 or more bloating episodes a month. Unexplained weight loss, even though your abdominal girth may be increasing, but you're losing weight unexpectedly, and having vague abdominal pains. So, those are signs of advanced ovarian cancer. Sometimes we'll see patients who they'll be diagnosed with some sort of pain in their abdomen or pelvis, and they'll get a CT scan or a pelvic ultrasound that shows the mass. Those patients are lucky if we catch cancer in the early stage, stage I, and you get about 99% out of 100 won't have cancer, but we take all these abnormal findings of radiographic masses around the ovaries, especially in the postmenopausal patients seriously, because yet we don't have any current screening tests to discover this type of cancer earlier.

Host: Well, after a diagnosis, how does the gynecologic cancer team deliver care at FirstHealth?

Michael Sundborg, MD: Yeah. So, we deliver at FirstHealth state-of-the-art care. We're very lucky to have that FirstHealth supports women's cancer care here. So, they give us all the resources. So, having gynecologic oncologist, there's two of us here. Usually, we're at places like UNC, University of North Carolina, Chapel Hill, or Duke University, at major medical centers. But FirstHealth wants this type of care. And we have the population that's affected with cancer, we can support that. We have gynecologic pathologists here, as most hospitals don't have that. We have two, one from UNC and one from Duke. Actually, the one from UNC is my wife. I stole her from UNC. So, we're very, very lucky to have that level of sophistication in diagnosing of these gynecologic cancers.

This new cancer center, four storeys, $68 million, all paid for by the community that delivers state-of-the-art care in terms of our treatment for patients. We have an excellent support staff in Radiology, Interventional Radiology, Radiation Oncology. So, when a person's diagnosed with a gynecologic cancer here, they get the same level of care they do at these tertiary medical centers.

And a real shout out for clinical trials. We have a very vibrant clinical trial section here where we're able to enroll patients into clinical trials. We can do that rapidly. There's a lot of bureaucracy with clinical trials in major medical centers, but we can get clinical trials rolling in about two months when we find a study that's very applicable for a certain cancer. And we've been recognized throughout the country and the world at FirstHealth for being able to enroll these patients. So, we deliver the whole shebang here.

Host: And all in a very hopeful way, very positive. And you mentioned state-of-the-art care. Looking toward the future, I mean, what is the outlook for gynecologic cancers? Technology is having a huge impact on progressing many areas of medicine. So, how is technology changing this field? Can you give sort of an idea of what you think it may look like in the next five or 10 years?

Michael Sundborg, MD: Yeah. We're making dramatic impacts. One tangible impact of that is that we do very advanced robotic surgery here now, where in the past where you had a gynecologic cancer, you would have surgery, you'd be in the hospital for 10 days, take about six weeks to recover. Now, with the advent of this minimally invasive, very sophisticated image-guided treatment with the robot, we can do the surgery where patients go home that day or the next morning, and they're recovered in several weeks and we can deliver rapid treatment afterwards. So, that's made a gigantic difference in my 10 years here.

Now because of conventional chemotherapy, we're adding immunotherapy and very targeted therapy for treatments of like endometrial cancers, which are making dramatic breakthroughs in terms of advanced cancers and response and towards cure. So, that's very exciting, and I think that's the key for cancers where we're now getting targeted therapy when we're looking at cancers where we can see the individual differences. This is what personalized cancer care is all about. If you look under a microscope, one person's ovarian cancer looks like someone else's, but it's what's under the hood, what's in the nucleus, all the mutations that individual person whose cancer has made, that now we're making these dramatic changes where we can have targeted therapy for.

And a good example is for ovarian cancer, we've discovered where we can disguise a very common chemotherapy called Taxol to make it look like a folate mineral or vitamin. And for some, about 20% ovarian cancers, have these increased receptors. Well, they'll grab that chemotherapy, bring it into the cell and it blows up inside the cancer cell, but not affects the other normal cells. So, it's amazing differences we're making.

I think in the near future, especially in ovarian cancer, there's certain things that we look at in terms of early detection. There's something called circulating tumor cells that are making a dramatic appearance on the ability to diagnose certain cancers early. So, you're looking at fragments of cancer cells that are in the bloodstream. These are called liquid biopsies, and that may change the game for ovarian cancers.

And finally, for ovarian cancers, like I said, we haven't really changed the survival rate, but we've changed the meaningful extension of life with these therapies. We're now looking at treatment methods that affects the DNA of the ovarian cancer cells in terms of inhibiting its repair. These are called PARP inhibitors. And so when patients are diagnosed with ovarian cancer, and then once they get their initial treatment with surgery and chemotherapy, these are oral medications we're giving patients, and we're seeing dramatic extension of life, and maybe even cure that we haven't seen before.

So, it's exciting times when it's coming to treating these cancers. And cervical cancer, again, that vaccine is so important. If we can get everyone vaccinated, we probably, just like smallpox, might eliminate that scourge of cervical cancer in our patient population.

Host: That would be a really wonderful future. And with the minimally invasive therapies you're talking about, early detection, and also the personalized care where every cancer is different, and you're able to see that more and more, it seems like those are going to make huge strides ahead in cancer care.

Michael Sundborg, MD: Yes. And I think the other thing about and we at FirstHealth being up to speed or at the same level of these tertiary care centers, we have our supported staff of nurse navigation. So, we have a nurse that's assigned to a particular cancer system like gynecologic cancer, gastrointestinal cancers and, you know, cancer is a very complex thing when you're diagnosed with this. It really affects the entire family, affects your finances. But having a nurse navigator who's my equal partner to help a patient navigate through the treatment options, all the issues with supportive care is so important. We're so lucky to have nurse navigators. And we have financial navigators here, because cancer causes financial toxicities, even with insurance. So, we're in FirstHealth is very altruistic in taking care. We deny no one care here. And having all the other social work, nutritionists, our infusion center, I've never in five major medical centers where I've given chemotherapy, I've never seen a more caring group of nurses taking care of our patients when they're getting their chemotherapy.

And I think the difference between us and the other major medical centers is that even though we're delivering this state-of-the-art care, we're very personalized. We have a very community-oriented aspect to our treatment. Our patients have access to us 24/7. I think that makes a big difference and knowing that, when you get diagnosed with cancer, you feel like you've lost control, and I think we do a very good job of putting the patient back in charge of their healthcare and making them feel like they can have some control over their disease.

Host: That's right. Because as a cancer patient, you can control what you can. And you have some great resources, great support, a fantastic team that knows how to use their state-of-the-art facility. So, it's really good hands you're putting yourself in with this team.

Michael Sundborg, MD: I totally concur, 100%

Host: well, Dr. Sundborg, thank you so much for that insight into the future, as well as this education on gynecologic cancers.

Michael Sundborg, MD: Thank you, Amanda.

Host: That was Dr. Michael Sundborg, Gynecologic Oncologist at FirstHealth of the Carolinas. To learn more about FirstHealth Cancer Care, visit firsthealth.org/cancer. If you found this podcast helpful, please share it on your social media and check out our podcast library for more topics of interest to you.

I'm Amanda Wilde. Thank you for listening to FirstHealth and Wellness podcast brought to you by FirstHealth of the Carolinas.