Published: 25 May 2023
Gynaecological cancers make up around
10% of all cancer diagnoses among females
in New Zealand; endometrial is the most
common, followed by ovarian and cervical. Vulval
and vaginal cancers are rare. There are significant
ethnic inequities in the incidence of gynaecological cancer,
with Māori and Pacific peoples disproportionately affected.
Although many gynaecological cancers cannot be prevented,
the cervical screening programme can detect early changes
indicative of cervical cancer, HPV vaccination can significantly
reduce the risk of cervical, vulval and vaginal cancers and
addressing modifiable risk factors such as obesity can
reduce the risk of endometrial cancer. The early detection
of gynaecological cancers is important as this is generally
associated with a good prognosis and high five-year survival
rates. Early detection, however, can often be challenging,
particularly for ovarian cancer, as symptoms and signs tend to
be non-specific and commonly related to another cause, e.g.
abdominal or pelvic pain, abdominal bloating or distention,
abnormal uterine or vaginal bleeding or discharge, urinary or
bowel dysfunction.
The diagnostic workup of a patient with suspected
gynaecological cancer typically includes:
- A focused patient history, considering relevant risk factors
- A pelvic examination, including speculum and bimanual
examinations (depending on the type of cancer
suspected); with cervical screening if due and swabs for
sexually transmitted infections, if indicated
- Laboratory tests, depending on individual factors, e.g. full
blood count, ferritin, thyroid stimulating hormone, CA
125 (if ovarian cancer suspected)
Further investigations will be initiated, or referrals organised,
depending on the type of cancer suspected after examination,
e.g. pipelle biopsy and referral for pelvic ultrasound for patients
with suspected endometrial cancer, gynaecology referral
for patients with suspected vulval cancer. If gynaecological
cancer is detected, patients will undergo management in a
Gynaecological Oncology centre.
Follow-up and surveillance of patients who have undergone
curative-intent treatment for gynaecological cancer is an
opportunity to identify recurrence as early as possible, and therefore optimise outcomes. In the majority of cases,
gynaecological cancer recurs locally in the pelvic region
within the first two to three years following primary treatment.
If identified early, most local recurrences of gynaecological
cancers are treatable and potentially curable.
Cervical cancer
See: Cervical cancer – early detection and referral
The risk of cervical cancer is significantly reduced through HPV
vaccination and cervical screening programmes, however,
there are still an average of 171 females newly diagnosed with
cervical cancer each year (from 2015 – 2020) in New Zealand.
Upcoming changes to the cervical screening programme
in New Zealand in 2023, including moving to HPV primary
screening, are predicted to further reduce the burden of
cervical cancer.
- Were you surprised at the high proportion of cervical
cancers that can be prevented by prophylactic HPV
vaccination? Does this change your perspective on the
importance of HPV vaccination, e.g. would you be more
likely to use an opportunity within a consultation with a
young person to encourage vaccination? Are you aware
of what proportion of the eligible patient population at
your practice is fully vaccinated against HPV?
- Māori and Pacific peoples have higher rates of cervical
cancer and are less likely to attend cervical screening.
What strategies does your practice currently have in
place to increase eligible patient’s participation in
the National Cervical Screening Programme? If none,
what sort of things could you do? How do you have
a conversation about screening with a patient who
is overdue or has never been screened/previously
declined?
- What are your thoughts about the new HPV testing
pathway being introduced from July, 2023? Do you
think that patients will be more likely to participate with
self-testing? Do you anticipate any problems with the
new programme? If so, what could be done to mitigate
this?
- In your experience, what symptoms and signs have
patients who have been diagnosed with cervical cancer
presented with? Would you say that most patients with
cervical cancer detected through the cervical screening
programme have been asymptomatic?
Ovarian cancer
See: Ovarian cancer – early detection and referral
Ovarian cancer is the second most common gynaecological
cancer in New Zealand after endometrial cancer, with an
average of 371 females newly diagnosed each year (from
2015 – 2020). Ovarian cancer can be challenging to diagnose
as there is no reliable screening test and symptoms may be
subtle and non-specific. Diagnosis at an early stage offers
a significant survival benefit. Clinicians should be alert
for potential symptoms of ovarian cancer and have a low
threshold for initiating further investigations.
- Symptoms and signs of ovarian cancer are often non-specific
and commonly encountered in primary care.
How do you differentiate the cause of these symptoms
and what is your threshold for suspecting ovarian cancer,
e.g. presence of risk factors, new or worsening symptoms,
symptoms without a likely explanation?
- In your experience, how common is the cause of ovarian
cancer a hereditary cancer syndrome? What is your
approach to the management of a patient at high risk of
ovarian cancer, e.g. a patient with a BRCA mutation?
- Referral for an urgent pelvic ultrasound is generally
the first-line investigation for a patient with suspected
ovarian cancer. How achievable is this in your region for
the patient to have an ultrasound within two weeks?
In your experience, what is the typical timeframe from
pelvic ultrasound referral to completion, report and
review?
Endometrial cancer
See: Endometrial cancer – early detection and referral
Uterine cancer is the most prevalent gynaecological cancer in
New Zealand, with an average of 627 females newly diagnosed
each year (from 2015 – 2020). Endometrial cancer accounts for
the majority of uterine cancer diagnoses. Excessive exposure
to endogenous or exogenous oestrogen unopposed by
progesterone is aetiologically linked to most endometrial
cancers. Obesity is one of the most significant risk factors with
an estimated six out of ten diagnoses of endometrial cancer
attributed to this.
- Prior to reading this article, were you aware of the extent
of the disparity for Māori and Pacific peoples in terms
of endometrial cancer? What about the significant link
between obesity and endometrial cancer? How do
you balance educating patients about risk factors and
encouraging a healthy lifestyle with positive messaging
that focuses on the benefits of early detection?
- What symptoms and signs would make you suspicious of
endometrial cancer? Have you had any patients recently
who have been diagnosed with endometrial cancer; if
so, what were their symptoms and signs? Is awareness of
symptoms and signs of endometrial cancer something
you discuss regularly with patients?
- Is training for pipelle biopsy available in your area? If
you have received training, how confident are you in
performing a pipelle biopsy? If you do not have training,
is there a clinician who can perform the procedure at
your practice? If not, who do you refer to and what is the
typical wait time?
Vulval and vaginal cancer
See: See: Vulval cancer – early detection and referral and
Vaginal cancer – early detection and referral
Vulval and vaginal cancers are the least common types of
gynaecological cancer in New Zealand. Most vulval cancers
are squamous cell carcinoma and are usually related to highrisk HPV infection or vulval inflammatory disorders such as
lichen sclerosus. The majority of primary vaginal cancers are
also squamous cell carcinoma; however, these are rare. Instead,
most cancers affecting the vagina are secondary, involving
metastases from another site such as the cervix.
- Have you ever had a patient diagnosed with vulval or
vaginal cancer, and if so, what were the symptoms or
signs that made you suspect it? Have you ever identified
a suspicious vulval or vaginal lesion as an incidental
finding?
- Before reading this article, were you aware of the
increased risk of vulval cancer associated with lichen
sclerosus? Thinking back to if there was a time when a
patient of yours was diagnosed with lichen sclerosus, did
you discuss vulval cancer risk? What, if any, surveillance
or follow-up plan was put in place?
- When the cervical screening programme changes to HPV
testing with the option of self-testing, how do you think
this will affect opportunistic detection of lesions or other
abnormalities? In your experience, do patients tend to
notice lesions themselves first anyway?
Follow-up and surveillance
See: Gynaecological cancers – follow-up and surveillance
Follow-up and surveillance of patients who have undergone
curative-intent treatment for gynaecological cancer is an
opportunity to identify recurrence as early as possible, and
therefore optimise outcomes. Most cases of recurrence
occur within two to three years post-treatment and patients
are generally symptomatic; patients must be encouraged to
seek advice if symptoms occur between scheduled follow-up
appointments.
- Are you currently involved in the management of any
patients post-treatment for gynaecological cancer? If so,
what is your role?
- Were you surprised that evidence shows that most
patients experience gynaecological cancer recurrence
within two to three years post-treatment? Is this
generally the case in your experience? Were you aware
that vulval cancer may recur at a much later time than
other gynaecological cancers?
- In your experience, how do you find patients cope after
having treatment for gynaecological cancer and being
faced with the potential for recurrence? What strategies
have you found successful at improving the mental
health and wellbeing of these patients? Do you have any
support groups in your area that you recommend?
