The management of advanced gynecologic cancers remains a challenge, but the treatment landscape is changing for cervical, ovarian, and endometrial cancers.

Paula Anastasia, MN, RN, AOCN, a nursing education consultant, reviewed data on gynecologic cancers and discussed the diagnosis and treatment of these malignancies in an oral presentation at the 2023 ONA Summit Live Virtual Meeting.

Cervical Cancer

The American Cancer Society (ACS) estimates that 13,960 patients will be diagnosed with cervical cancer in 2023, and 4310 patients will die of the disease. Cervical cancer is the fourth most common cancer in women globally (570,000 cases; 311,000 deaths). The average age at diagnosis is 50 years.

Cervical cancer cases are almost exclusively related to human papilloma virus (HPV), and the cancer is almost 100% preventable with HPV vaccination. HPV vaccination reduced the incidence of cervical cancer by 65% from 2012 to 2019.

More than 80% of cervical cancer cases are squamous cell carcinomas, with 59% of cases due to HPV-16 and 13% due to HPV-18. Adenocarcinoma accounts for 20% of cervical cancer cases; 36% of them due to HPV-16, and 37% due to HPV-18.

The incidence of squamous cell carcinoma has declined due to screening, but the incidence of adenocarcinoma has increased over the past 30 years because diagnosis via Pap smear is less effective for this histology.

Diagnosis is made by Pap smear, cervical biopsy, cone or loop electrosurgical excision procedure (LEEP) biopsy, or endocervical curettage. Imaging options used to assess disease stage include chest radiography, computed tomography (CT), positron emission tomography (PET)/CT, or magnetic resonance imaging (MRI).

Treatment options include surgery, radiation, chemotherapy, targeted therapy, and immunotherapy. Stage at diagnosis has a significant role in treatment options. Surgical options (fertility-sparing or non-sparing) are recommended for early-stage disease. Surgery or systemic therapy may be appropriate for advanced stage disease. Systemic therapy is usually recommended for distant metastasis or recurrent disease.

Newer treatments used as second-line or subsequent therapies include nivolumab for PD-L1-positive tumors, pembrolizumab for PD-L1-positive or microsatellite instability-high/mismatch repair deficient (MSI-H/dMMR) tumors, tisotumab vedotin-tftv, and larotrectinib or entrectinib for NTRK gene fusion-positive tumors.

Ovarian Cancer

The ACS estimates that there will be 19,710 new cases of ovarian cancer in 2023 and 13,270 new deaths due to the disease, although the incidence of ovarian cancer has declined 1% to 2% over the past 20 years. The average age at diagnosis is 63 years.

Ovarian cancer is the most fatal gynecologic malignancy, as it is commonly diagnosed at an advanced stage. Use of oral contraceptive pills and postmenopausal hormone replacement may lower the risk of disease.

Genetic variants play a significant role in ovarian cancer. Therefore, all women should undergo genetic counseling and testing to facilitate treatment decisions.

The genes most commonly associated with ovarian cancer are BRCA1 and BRCA2 (10% to 15% of cases). However, up to 40% of patients with BRCA1/2 mutations have no known family history. Other genes identified as high risk include BARD1, BRIP1, MLH1, MSH2, MSH6, PALB2, PMS2, RAD51C, and RAD51D.

Diagnosis cannot be determined by imaging. Tissue or cytology testing is required (paracentesis, thoracentesis, or needle biopsy via laparoscopy or laparotomy).

The typical course of treatment is surgery plus primary or adjuvant chemotherapy (with or without bevacizumab), followed by surveillance over 3 months and/or maintenance therapy until relapse or disease progression.

In cases of platinum-sensitive, recurrent ovarian cancer, patients initially achieve complete remission but experience recurrence 6 months or more after completing their last platinum-based chemotherapy. These patients tend to have a good prognosis. Retreatment with a platinum combination is suggested, as well as considering a clinical trial option.

In platinum-resistant disease, recurrence happens less than 6 months after completing platinum-based chemotherapy. Platinum-refractory disease will progress during the initial platinum-based chemotherapy. Both of these groups have worse prognosis.

Endometrial Cancer

ACS estimates for new cases of endometrial cancer and deaths in 2023 are 66,200 and 13,030, respectively. The average age at diagnosis is 60 years, with 25% of cases in premenopausal women and 5% of those in women younger than 40 years.

Endometrial cancer is the most common gynecologic cancer (7% of cancers in women). From 2007 to 2016, the incidence increased 1% per year in White women and 2% per year in Black women. The mortality rate increased 2% per year in Black and White women.

Treatment is based on stage, grade, and depth of invasion. Options include surgery, which may be curative with no adjuvant therapy; pelvic radiation or brachytherapy; and radiation and systemic chemotherapy. Options for women with pre-invasive disease who wish to preserve their fertility include hormone treatment, endometrial sampling, and surveillance.

Treatment options for advanced or recurrent metastatic endometrial cancer are limited. However, pembrolizumab is approved for second-line therapy in MSI-H/dMMR tumors, and dostarlimab has produced responses in advanced disease (MSI-H, MSI-stable, dMMR) that progressed on prior therapy. Pembrolizumab plus lenvatinib is approved for second-line therapy in MSI-stable tumors.

Challenges in the management of patients with advanced gynecologic cancers include unpredictable timing of long-term and late-onset immune-related adverse events and the need for coordination of care and multidisciplinary management.

Nurses should discuss with patients the differences between adverse events related to chemotherapy and those related to targeted therapies or immunotherapy. Nurses should also assess the patient’s ability to follow telephone instructions and consider strategies to overcome language barriers, cognitive deficits, alcohol and drug use, and comorbidities. Nurses should also assess the patient’s comprehension of “sense of urgency” to determine the need for caregiver engagement and/or home care services.

Reference

Anastasia P. Advanced gynecologic cancers: Pathogenesis, treatment, and management of complex diseases. Oral presentation at: 2023 ONA Summit Live Virtual Meeting; March 17-19, 2023.