Pamela Soliman, M.D. Hi, I'm Dr. Pamela Soliman, a professor in the department of Gynecologic Oncology here at MD Anderson Cancer Center. I'm joined today with one of my esteemed colleagues, Dr. Shannon Westin, who's also a professor in the department of Gynecologic Oncology. Thank you so much for joining us for this Cancerwise podcast today. 

Shannon Westin, M.D. I'm so excited to be here. Thanks for having me. 

Pamela Soliman, M.D. We're here to talk about what women should know about gynecologic cancers. Shannon, maybe tell us a little bit about what you do as gyn oncologist. 

Shannon Westin, M.D. Yeah, I mean, I think it's really important to understand because it can be really confusing about what exactly we do. So, gynecologic oncologists are the ultimate doctor, right? So, we do surgery and we give treatment for gynecologic cancers. But, it's important to know that we don't treat all women's cancers. We typically will treat below-the-belt women's cancers. So, uterine cancer, ovarian cancer, cervical, vaginal, vulvar. We do not treat breast cancer. But, I think that we would all agree that as gynecologic oncologists, we have the opportunity to provide the most comprehensive care because of the way that we touch all pieces of the woman's journey. 

Pamela Soliman, M.D. And then maybe talk a little bit about which cancers you treat, and we can talk about how to screen for them or what people should know in general. 

Shannon Westin, M.D. Sure. I mean, I can start with just our cancers in general. So, let's start with the reproductive organs, right? So, we have the uterus. And that is where a baby will grow when we have a pregnancy. But, the cancer can start either inside the uterine lining, which is called the endometrium, or in the muscle wall, which can be called a sarcoma. We also can see cancers that start just in the cervix, so on the outside of the womb, and then even going out to the external female genitalia, like the vulva and the vagina. And then finally, we can see cancers in the ovary, or along the fallopian tube, or in the inside lining of the abdomen, which is called the peritoneum. And those are all kind of loosely grouped as something called ovarian cancer and treated the same. So, let me ask you this: I think there's a lot of confusion out in the community around the Pap tests and what it actually can show. 

Pamela Soliman, M.D. So, that's a great question and something that we're often asked, like, "Oh, I had a Pap smear. Doesn't that screen for ovarian cancer?" And the reality is, no, it doesn't, OK? So, the main reason you have a Pap smear is for early detection of a pre-cancer or dysplasia so that we can prevent cervix cancer. I think going to the doctor also enables you to have a pelvic exam and have a discussion about any symptoms that you're looking at or anything different, and those can be helpful to find some of the other gynecologic cancers. 

Shannon Westin, M.D. And that makes sense. And I guess the other the question that comes up then is: how does somebody out in the community get screened for, say, ovarian, or peritoneal or fallopian tube cancer? Are there any mechanisms that work well for that? 

Pamela Soliman, M.D. Yeah. No, that's again, something that we're asked commonly. So, endometrial cancer is the most common gynecologic cancer that we see. Risk factors include being overweight or obese, things like diabetes, hypertension, something called PCOS or polycystic ovarian syndrome. So, there isn't a screening test for endometrial cancer, but endometrial cancer often presents with a symptom that women recognized as abnormal. And so, we tell women if you're having irregular periods, so you're bleeding in between your periods, they're very unpredictable, all of a sudden, they change and they're very heavy, that's something you should let your doctor know about. In women who've already gone through menopause, any bleeding at all, so even a drop of blood, that's like a red flag that something may be going on. So, even though there isn't a screening test, these, like, physical signs that most women recognize as abnormal will lead them to go to their doctor. And if they go to their doctor and they report these things, then they'll have an evaluation, either a pelvic ultrasound to look at the lining of the uterus, or sometimes an office endometrial biopsy where we take a small straw, put it inside the uterus, and then take out some cells. And that's a way that we can find endometrial cancer. And fortunately, because people recognize these are abnormal symptoms, most women are diagnosed with early-stage disease. Maybe switch gears and talk a little bit about ovarian cancer screening and kind of what's going on with that. 

Shannon Westin, M.D. Yeah, I mean I think ovary cancer has been tough because there are some ways that we can screen for it. You already mentioned some of them. Right. So, an ultrasound is a way. We can use a blood test, something called a CA-125, which may or may not be elevated in the setting of ovarian cancer. But, I think the issue is we've not been able to find a universal screening. So, there's no recommendation at this point, if you go to your regular gynecologist or your regular internal medicine physician, that there's anything that should be done to look for ovarian cancer if you're without symptoms or any other history. So, the symptoms that would raise our eyebrows or make us concerned that there could be the presence of ovarian cancer is kind of subtle. They're symptoms that are often really easy to blow off, right? So, abdominal pain, nausea, bloating, kind of, not fitting quite well in our clothes, weight gain, weight loss. And it's easy to blow it off and be like, "Oh, maybe I'm lactose intolerant, or I need more fiber in my diet, or I'm allergic to gluten." You know? So, I think it's very easy to put those symptoms off on something else. But, if we're seeing those types of persistent symptoms, then we would want to move forward to do some screening. And that's the same things that you just talked about. So, ultrasound, lab and really more advanced imaging. So, you know we personally love as gynecologic oncologists when someone has gotten a CT, a CAT scan of the abdomen and pelvis, because we get a really good look and can understand what's going on. I think, you know, in a person that has increased risk, and this would be people that have either a genetic predisposition to the development of ovarian cancer or other extensive exposure to estrogen, so early menarche, early start of menses or late menopause, so when everything stops, if they haven't had a lot of kids, so they've been exposed to estrogen for longer times, you know, or if they're taking estrogen, you know, those types of things could put us at higher risk and may warrant a little bit more careful screening. I would love to, kind of, to switch gears a little bit and talk about the genetics. Do you want to tackle the genetics of endometrial cancer because that's something you've done a lot of work in? 

Pamela Soliman, M.D. Yeah. So, I think, you know, when many patients are diagnosed with cancer in general, the first thing they want to know is, "Oh, why did I get this? Are my kids at risk for getting this? You know, is this genetic?" And for most women with endometrial cancer, fortunately, it's not genetic. And there are other risk factors like we talked about: overweight, obesity and things like that. So, if you take all women that have endometrial cancer, only about 2% to 3% are caused by a genetic syndrome, something called Lynch syndrome. It's a gene that we carry, and we can pass on to our children, about 50% chance of passing it on to your children, that increases your risk for several cancers, including endometrial cancer. So, if a person has Lynch syndrome, then their lifetime risk of developing uterine cancer is about 60%. So, many women will get uterine cancer. And then, it also increases your risk for other cancers. So, among the gynecologic cancers there is a slight increase in ovarian cancer. So, we didn't really talk about it. But the general population of risk of ovarian cancer is a little bit less than 2%. So, if you're not in the high-risk category, the risk you're going to get it is relatively low to other cancer types. But, if you have Lynch syndrome, it can be up to 10% lifetime risk. So, it does increase for that. In women that have a genetic mutation, then we can also test their children. So, that gives us an opportunity to understand whether their siblings or their children are also affected. And if they are, then it allows us to implement a different screening and a more proactive management style. So, for example, if my mom had uterine cancer years ago, and she was tested and found to have Lynch syndrome, and then I got tested, and I know I have it, but I don't have cancer, what we generally do is recommend an endometrial biopsy annually. It also increases your risk for colon cancer. So, we do colon cancer screening earlier and more frequently than the general population. And then, once patients are finished with childbearing, we actually offer them preventative surgery. So, you can say, "OK, I'm 40 years old. I've had my kids. I want to go ahead and have a hysterectomy to prevent a future uterine cancer." 

Shannon Westin, M.D. And we see something similar with ovarian, peritoneal and fallopian tube cancer, where I think many of our listeners will be familiar with something called BRCA. And there's two pieces of BRCA. We have BRCA 1 and BRCA 2, as well as some more rare genetic syndromes that we can see, or abnormalities in the genes like RAD51C, RAD51D. But, the bottom line is when you have this abnormality in the gene, it puts you at a higher risk of the development of cancer, specifically breast cancer, as well as ovary, peritoneal and fallopian tube cancers. And just like you said, you know, if you have a family history of any of the cancers associated with BRCA, you may be at an increased risk. And specifically, when we talk about family history, we're looking at some specific features. We look for first-degree relatives, so, like, your parent or your sibling. We look at the age at which that cancer develops. So, younger age at the development of cancer is concerning for a potential hereditary syndrome. And then, we look to see the pattern within the family. Are there multiple of these types of cancers or even have you already had breast cancer? You might be at an increased risk of developing ovarian cancer. And so, when we know that we have these abnormalities it's a simple test, right? We can test your blood or test your saliva and look for the, kind of, most common genes that are abnormal. And if we identify that and you do not have cancer, just like what was, what you just said about Lynch syndrome, there are opportunities for screening. We use ultrasound, we use blood tests. We watch very closely. But then, just like with Lynch syndrome, when you hit a certain age, if you're completed with childbearing, there are opportunities for risk-reducing surgeries. And the standard risk reducing surgery for ovarian, and peritoneal and fallopian tube cancer is actually removal of the ovaries and fallopian tubes. Although, there's some really exciting research going on looking at maybe if we could just take out the fallopian tube, which may be kind of the worst actor of the three. And so, I think understanding your family history that your symptoms, and what you're at risk for is really important because, you know, here at MD Anderson, we have some really awesome high-risk screening clinics where you don't have to worry. You're plugged into the clinic, and they will walk you through the process of the types of testing that you need, and also, you know, the types of interventions that might be appropriate for you to reduce your cancer risk. So, I think it's really important to know all these things that we just talked about so that you can identify your own risk and potentially get involved. 

Pamela Soliman, M.D. Yeah, I think the only thing I would add to that is for people listening and they're thinking, "Oh, my mom had this and my dad had that." And, you know, I think that's our responsibility as physicians to help you understand your family history. So, I think the most important thing is that you reach out and you talk to your doctor, whether it's your, you know, primary care doctor for your annual visit, your gynecologist to sort of advocate for yourself. I think you mentioned, kind of, ovarian cancer having subtle symptoms. And I think it's kind of the same thing. Like, you have a responsibility to tell your doctor, I'm having A, B and C. Because the symptoms are so common, they'll be like, "Oh, it's probably GI, we might send you for a colonoscopy." We see this all the time. And then, people are like, "OK," but they continue to have symptoms, but they don't go back. And so, I always tell people, you are your biggest advocate. So, if something isn't right and something's changed, go to your doctor. If they say everything's OK and it's persistent, go to your doctor and keep going until they do something about it. And I think talking to them about your family history and asking questions is also part of advocating for yourself. 

Shannon Westin, M.D. Yeah, and I think if you are identified to have, either to be at risk for a gynecologic malignancy, or even if you have a gynecologic malignancy, I think the next step is going to a specialist, right? And I think that we can't say this enough, there's been data across all of the different gynecologic cancers, cervical cancer, uterine cancer, ovarian cancer that the best outcomes come when you see somebody in a high-number setting. They see a lot of this. They know what to do. They're going to use guideline-concordant care. It is essential to see a gynecologic oncologist, and it's essential to make sure that the person you're seeing sees more than one of you, right? So, they're experienced. You're not the first person they've ever seen with this, that or the other. So, I really do think that advocacy goes beyond even once we get the diagnosis and making sure you're in the right place, getting the right treatment. 

Pamela Soliman, M.D. Yeah. And I think sometimes we'll hear patients say, "Oh, I went to my doctor and they said, 'Oh, well, we'll just take it out and see what it is. And then we'll send you.'" I think particularly if you're a postmenopausal, if you have ovarian masses, there's an opportunity for us as oncologists to do everything at the same surgery. So, for example, if you go and you have just your ovaries taken out, oh, and then it's cancer, then you may have to go back to surgery for the staging procedure or additional information. One of the benefits of coming somewhere like here or seeing a gyn oncologist is we can do that evaluation while you're under anesthesia and asleep, get that information and then action on it at the same time. So, it often helps expedite care. And I think that's why studies have shown that patients have better outcomes. 

Shannon Westin, M.D. Yeah. And I think even if you're getting a risk-reducing surgery, it can be really important where you get that done, right? Because you and I both know that when we take out ovaries, or fallopian tubes, or a uterus in patients that are at a hereditary risk for cancer, they need to be processed in a very specific way and assessed in a very specific way so that we don't miss any early evidence of pre-cancer or microinvasive, tiny, tiny bits of cancer that would need to be treated and, if missed, could lead to a subsequent recurrence of disease or, you know, inadequate care. And so, I think where you go first really matters and making sure that you're getting that appropriate, guideline-concordant care in the hands of an expert is really going to be important. Wow, we covered a lot of ground today.

Pamela Soliman, M.D. So, one more thing I thought of that often comes up when we, kind of, talk about screening and things like that is patients say, "Well, isn't CA-125 a marker for ovarian cancer? Can't I just get that? And isn't that going to help me screen for ovarian cancer?" So, what do you say when people ask you that. 

Shannon Westin, M.D. Yeah, I mean it's, I wish it was, right? So, I think the issue has been when we've looked at studies where we just get CA-125s on everybody, we end up doing too much. We end up taking people to surgery, having worse outcomes, having issues happen, and we don't actually find a higher number of cancers. So, it doesn't work the way we would like. And I would say there's a lot of really smart people doing really great work, trying to find other markers or algorithms that will help us identify people that have early ovarian cancer or are at risk, but at this point, we do not recommend doing CA-125 on everybody. 

Pamela Soliman, M.D. Awesome. Well, it's been so great sitting down with you. We work together, but we never sit down together and talk. So, thank you so much for joining us today for this enlightening conversation. And thank you for tuning in today. If you enjoyed this episode, be sure to follow or subscribe on Apple Podcasts, Spotify, YouTube or whatever you get your podcasts on. And don't forget to comment or review. For information or to request an appointment at MD Anderson, call 1-877-632-6789 or visit MDAnderson.org. Thanks for listening to the Cancerwise podcast from MD Anderson Cancer Center.