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Scott Webb: Gynecologic cancer is a complex topic with several subtypes. Today, we'll be talking about the three common types of gynecologic cancer, cervical, endometrial and ovarian cancer. These three types of cancer can often have similar symptoms, which can sometimes be confused or misdiagnosed as menstrual problems. Being aware of the symptoms, your normal body function, and having regular gynecologist visits can all help diagnose cancer earlier for better outcomes. From signs and symptoms to treatment options, Dr. Tina Ayeni is here to share what women should know.

This is the Franciscan Health Doc Pod. I'm Scott Webb. Webb Dr. Ayeni, it's great to have you on again. Today, we're going to do sort of a part two episode. Today, we're going to focus more specifically on gynecologic cancer and, you know, what women need to know. So as we get rolling here, what are the general factors that increase the risk for gynecologic cancer in women?

Dr. Tina Ayeni: For many of the gynecologic cancers, we do have a good understanding of the different risk factors that can lead to development of those cancers. So, gynecologic cancer in general is a catchphrase. Specifically, the more common cancers that I see under that umbrella would include cervical cancer, ovarian cancer, and endometrial cancer.

With cervical cancer, we know that over 99% of these are caused by infection. It's an infection by a virus called HPV, human papilloma virus. This is a virus that is sexually transmitted. Oftentimes women don't have symptoms. They don't know that they have been infected by this virus. But the way that this virus acts is it causes cells on the cervix to turn from normal to pre-cancer and then to cancer. It's a pretty predictable transition. Usually, those changes take years. And so, that's why Pap smear screening is so important. Because hopefully by getting your Pap smears, we're catching some of these cell changes early in the game so we can deal with those changes, get rid of them, and prevent you from ultimately getting cancer. But we do know that for cervical cancer, HPV infection is the driver.

When it comes to ovarian cancer, really the largest risk factor for development of the most common ovarian cancers that we see is a genetic mutation. This refers to the DNA that you inherit from your mom or dad. If there are portions of that DNA that do not work well, that is what increases the risk for development of cancer. And ovarian cancer can be seen in over 20% of those cases due to a genetic mutation.

In terms of endometrial cancer, the endometrium is the central cavity of the uterus. That's the tissue that grows every month to prepare for a pregnancy. And if there's no pregnancy, that tissue sheds off and give the woman her period. But within that tissue, you can actually get cancer development. And the most common cause for development of endometrial cancer is obesity, being overweight. Fat cells in our bodies make estrogen, and estrogen is a hormone. It's also food that feeds that lining, causes that lining in the central cavity of the uterus to grow and grow. And if you have persistent growth that's unregulated, that's how you can get those normal cells transitioning to often pre-cancer, and then to cancer. So, obesity is a big cause of endometrial cancer. And of all the gynecologic cancers that I see, endometrial cancer is the most common.

Scott Webb: Yeah, the most common. And I know that each type is a little different, right? So, what are some of the risk factors that increase a women's chance of cervical cancer and ovarian cancer specifically?

Dr. Tina Ayeni: Yeah, the risk factors that increase the chance for those cancers specifically. So, not only is cervical cancer caused by HPV infection, there's some other important risk factors to think about with cervical cancer. Smoking tobacco, absolutely, it makes that virus work better in your system. The other risk factor with development of cervical cancer is infrequent Pap smear screening. So what I mean by that is right now the guidelines are, depending on your age, about every three to five years, your Pap smear is going to be due. For women who go long stretches of time, like 10 years, 20 years between pap smears, that by itself is a risk factor for developing cervical cancer. Because, like I said, most cervical cancers start with a pre-cancerous change. And what we're trying to do with the Pap smear is catch those pre-cancer changes, treat those to help prevent the cancer. So if you're going 10, 20 years with no pap smear, we're not catching those pre-cancerous changes. And so by the time you come back, maybe cancer has already started.

In terms of ovarian cancer, aside from the genetic mutation, you know, age is the other big risk factor for ovarian cancer. , most of my patients on average are in their mid sixties when they, , are, , being diagnosed with the most common forms of ovarian cancer. It is a rare disease. You know, even though ovarian cancer, we often get scared by the mention of that particular type of cancer, because it can be very difficult to treat and rarely can we cure it, but it's rare. The general population risk is about 1.3%. But again, the genetics are the most important risk factors that we have identified. And for some women with those genetic mutations, that risk can increase to 50% risk in their lifetime. So, genetics, genetics, genetics is the underscore with ovarian cancer risk.

Scott Webb: Yeah. And doctor, I've read about these cancers. And one of the common themes is that the signs and symptoms are often not noticed or they're incorrectly attributed to abnormal menstrual cycles or even menopause. Maybe you could talk about each type and what symptoms are important to look out for.

Dr. Tina Ayeni: When it comes to cervical cancer and endometrial cancer, the common signs and symptoms are abnormal bleeding. And those symptoms actually happen early in the course of the cancer development. So for cervical cancers, some women will notice bleeding after sex specifically. We call that post-coital bleeding. Sometimes bleeding between your menstrual cycles if you're a younger woman, that also can be a sign of an existing cervical cancer.

With the endometrial cancers, the uterine cancers, women may notice that they're having bleeding between their cycles, abnormal bleeding instead of having a menstrual cycle once a month. Their cycles are happening on an irregular pattern. They may notice that their cycles are much, much heavier than previous. So maybe they're still having cycles once a month, but it's a much heavier flow, that sometimes can be a sign of an endometrial cancer. And then for women who are in their post-menopause years, meaning that they are no longer having menstrual cycles, absolutely, any kind of bleeding, once you've entered into menopause is abnormal. Sometimes that bleeding can be due to a benign condition. Benign conditions are not cancer like polyps. But I wouldn't assume. Once you've hit your menopause years, any kind of bleeding is considered abnormal and warrant a workup with your gynecologist.

In terms of symptoms for ovarian cancer, you know, for a lot of time in the medical field, even among professional colleagues, you know, we've often thought of ovarian cancer as being more of a silent type of cancer with not a lot of obvious symptoms. We're trying to rewrite the book on that. In fact, there are symptoms that are attributed to ovarian cancer and it's important that we understand what these symptoms are. Very commonly, women notice a change in their urination pattern, that is on the top three list of symptoms of women diagnosed with ovarian cancer. They will report that in the preceeding six to 12 months or so, they've had increased urinary frequency. And a lot of times when you're using the restroom a lot urinating frequently, you wonder, is this a bladder infection, urinary tract infection? Do I need to get antibiotics? And sometimes women will get those antibiotics and sometimes your symptoms do feel better, but they typically return. So, frequent urination is on the top three list.

The other common symptom that I see with ovarian cancer is new back pain. So many of us have back discomfort, ailing back symptoms. But if you're experiencing new symptoms that are different from your typical back pain, that is not something to ignore. That is definitely something to share with your primary care physician, so that they can do the appropriate exam and testing as indicated.

Scott Webb: Yeah. Most of us, as we get to a certain age and there's sort of like normal pains, normal back pain. But as you're saying, yeah, keep an eye out for something that's different, that's sort of emergent, that isn't like your usual back pain. And we talked about last time about the importance of women, you know, being seen every year, especially by their gynecologists. So, maybe you can talk about that and how important that yearly visit is and why that's such an important step to keeping women healthy.

Dr. Tina Ayeni: One of the things that's important is that an annual exam doesn't automatically mean a Pap smear. For so long, we've kind of associated the female pelvic exam with, "Oh, it's time for me to get my Pap." And honestly, Pap smears are due maybe every three to five years, depending on your age, sometimes every year, depending on your gynecologic health history.

But the one thing you absolutely need every single year without question is a female pelvic exam. Just like you go in to get your heart checked out, your lungs checked out. When you have your regular annual exam, those organs are always assessed, your pelvis needs to be assessed as well. The health of the vagina, the health of the bowels, all of those need to be assessed on an annual exam. And as you get older, a rectal exam should be part of that female pelvic exam. What we're feeling for in those exams is abnormalities. Sometimes I can see a lesion in the vagina that my patient is not having symptoms from. Sometimes when I place the speculum in, I can see that the cervix is not sitting in the right position. If it's shifted, that can be a sign that there's actually something going on with the ovaries. Maybe there's another mass in the pelvis that's causing the whole uterus and cervix to shift into an abnormal position. So, there are things that we capture on an exam that can give us a clue to something going on inside that our patients may or may not be having symptoms from. I definitely have personally diagnosed anal cancer, rectal cancers just based on the female pelvic exam. My patient may or may not be having changes in terms of their stool. So, the annual exam is very important to screen the pelvis to make sure that the organs feel normal, look normal. And then, like I said, your Pap smear, that's the perfect time for your doctor to to tell you, "When is your pap smear due? When do we need to get that screening done to help rule out cervical cancer?"

Scott Webb: Yeah, definitely. And wondering if cervical cancer is found on a Pap test, you know, discovered through physical exam with you or gynecologist or maybe the patient has noticed some symptoms, what are the treatment options available? I know it probably varies depending on cancer type and stage, but maybe you can give us an overview of the each types', you know, typical treatment.

Dr. Tina Ayeni: With the gynecologic cancers that I take care of, treatments can be really one of three, whether it's surgery, radiation or the last category I'd call is systemic treatment. Those are medications that course throughout your arteries and veins and touch every cell in your body, kind of like your chemotherapy.

 With many cancers, we are using multiple of those strategies, surgery, radiation, systemic or chemotherapy. For early stage cervical cancer, honestly, it's rarely that surgery is the treatment. For most women presenting with cervical cancer, the primary treatment is radiation with chemotherapy with no surgical intervention needed, because radiation often can melt the cancer away and give you just as good of a cure rate, as if we were going to tackle those tumors with surgery by themselves. So usually surgery, doesn't help the situation for most cervical cancers. And radiation with chemo tends to be the primary treatment strategy.

In terms of early stage endometrial cancer, it is kind of a different story. A lot of times, surgery is all you need. Sometimes we need a little bit of radiation after surgery, something that we call vaginal radiation, which is kind of a rare form of radiation, but minimal side effects. Usually, three treatments on average that are about 15 minutes in length. So, the treatment of endometrial cancer tends to follow more of a surgical pathway. Ovarian cancer usually is dual, is usually surgery and chemotherapy.

Scott Webb: Yeah. And you mentioned surgery there, and I've spoken with other doctors experts about the da Vinci robot. I love certainly, you know, robots and lasers because, you know, once you're 15, doctor, you're always 15. But maybe you could talk more about the da Vinci robot. What is it and why, you know, might women want to choose that, that minimally invasive option?

Dr. Tina Ayeni: The da Vinci robotic system really came onto the market in the mid-2000s, that's when we started using it in gynecologic cancer surgery procedures. Essentially, it's small incisions that we make in the belly cavity. And through those incisions, we put the arms of the robot machine. And so, the robot machine is actually standing next to my patient's bedside. I'm in the corner of the operating room using a computer, and that computer is almost like I fit my hands through a glove almost. It's not quite a glove, but it's kind of the same idea where I'm actually maneuvering the arms of the robot by moving my hands. So, the robot doesn't do anything without me giving the prompt. So, the robot arms move when I move. If I open my hand up, the robot arms open up. If I close my hands, the robot arms close. And so, I use my hands to do the surgery, but the robotic arms are actually in my patient's abdomen and completing those surgical tasks that my hands are signaling.

The other type of minimally invasive surgery is standard laparoscopy. That's where me, as a surgeon, I'm standing at my patient's bedside. And through those small incisions, I've got instruments that I'm holding in my hand and I put those instruments through my patient's abdomen incisions, and I'm using my handheld instruments to do the surgery.

So, both forms are considered minimally invasive, meaning we're doing surgery through small incisions. The best thing about minimally invasive surgery, whether it's laparoscopy, whether it's robotics, quicker recovery, you know, less incisions means less pain, less inflammation, less time that you need to stay in the hospital, quicker time to return to your baseline activities. So, those are all amazing benefits with minimally invasive surgery. One of the things I like about the robotic system a little bit more than laparoscopy is the fact that, with the robotic system, I can just get into tighter angles with more ease. So, my 360-degree rotation, that's something that you can get with the robotic system that you cannot get with laparoscopy.

Scott Webb: Absolutely. Yeah. Well, it's been so great learning more about this. It's so complex and yet you have such an ease with which you sort of break it all down, explain everything in lay terms, which is great for me, great for listeners, great for your patience, of course. I want to ask you, you know, when we think about people having choices where they can go. And so if a woman has been diagnosed with gynecologic cancer, maybe you can share why you would strongly encourage them, why you believe that they should come to Franciscan Health for their care.

Dr. Tina Ayeni: Yeah, absolutely. You know, here at Franciscan Health, we have a commitment to providing compassionate cancer care. We have a multidisciplinary team, and that's what it takes to take care of gynecologic malignancies. It's not just me as the gynecologic oncologist. I'm often the quarterback of the team, but it is a full team. We have our radiation doctors, my colleagues who will give the chemotherapy that I'm recommending for my patients. We have our professionals who are investigating clinical trial options for our patients. And we have a whole team of genetic counselors who helps to provide that next level of information that helps me to not only take care of my patients, but also to help take care of my patient's family. You know, is there genetic driver behind why my patient got this cancer? How can we keep the other women and sometimes men in her family safe and prevent them from getting similar related cancers? That is just a snapshot of who was on our team.

I think one of the biggest things with cancers, when you have multiple doctors, the communication has to be at its best. And we have a nurse navigator specifically for gynecologic cancers whose sole mission is to communicate with all of the different doctor teams. Sometimes my patients don't know who to call. Is it time for my radiation appointment today? Am I seeing my surgeon? Am I seeing my chemotherapy doctor? You know, when those things get confusing, you just make one phone call to our nurse navigator and she already knows your plan like the back of her hand, and she can help to direct you in real time to, "Hey, this is what's coming up today, tomorrow, next week." So, that nurse navigation is very important, and that's what we have here at Franciscan.

Scott Webb: Yeah. Nurse navigators, genetic counselors, survivorship support groups, tobacco cessation, the team and care with you often being the quarterback of that team. So yeah, we just want folks to know what's available for them. And doctor, as we close here and, again, another educational podcast for me and I'm sure listeners, maybe you can share with the audience, , what is most important for women to know about gynecologic cancer?

Dr. Tina Ayeni: One of the most important things is that it's very important that you have a gynecologic oncologist as part of your care team. You know, often that's going to mean traveling, traveling a distance for surgery or for a consultation or for special types of tests. But these short-term sacrifices can often be the difference maker when it comes to getting the best long-term outcome that you're looking for when you've had a diagnosis of a gynecologic malignancy. These are rare cancers. You really need to make sure that you have an a gynecologic oncologist who understands these diseases intimately to help navigate and quarterback the services that you need.

Scott Webb: Yeah. And as you mentioned earlier about nurse navigators, they are amazing. They know everything like the back of their hand, you know. And just the ability to just pick up the phone and say, "I'm confused. I'm not sure where I'm supposed to be, who I'm seeing." What a great advantage to choosing Franciscan Health. And a great advantage for me, doctor, and listeners, to have you on. It's so great to have your expertise. So, I'm sure we'll speak again sometime in the future. Thank you so much. You stay well.

Dr. Tina Ayeni: Absolutely. Thank you so much. Be well.

Scott Webb: To learn more about cervical cancer screening, visit franciscanhealth.org/screenings. Or to find a gynecologist in your area, visit franciscandocs.org. And if you found this podcast helpful, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.