Gynecologic Cancers

At the University of Florida, gynecologic cancer is managed with a team approach involving close interaction between a gynecologic surgical oncologist and a radiation oncologist who specializes in radiation therapy for gynecologic cancer. Before a treatment plan is recommended, most cases are discussed at a conference by a group of medical specialists with expertise in the diagnosis and management of gynecologic cancer. This type of conference is called a multidisciplinary tumor board. The gynecologic tumor board includes a gynecologic surgical oncologist, a gynecologic radiation oncologist, a specialist in pelvic and abdominal imaging from diagnostic radiology, a gynecologic pathologist, a nurse oncology specialist, and a social worker. Sometimes the patient is asked to come to the clinic while the tumor board is discussing her case so that some of the experts on the tumor board can speak to or examine her if this helps to determine the best treatment approach.

Cervix

The treatment approach for cancer of the uterine cervix usually depends on the size of the tumor, the location of the tumor relative to other pelvic tissues (like bladder, rectum, and pelvic side wall). The size and location of a cervix cancer is often described by a system called the FIGO staging system.

Small cervix cancers (small FIGO stage IB) that develop in healthy patients are usually treated surgically with an operation called a radical hysterectomy. After the operation the uterus and other tissues are examined under a microscope by a pathologist. If microscopic examination suggests that the patient is at high risk for cancer recurrence, radiation therapy is usually recommended. Radiation therapy in this setting usually involves 5 weeks of external beam radiation therapy (treatments given 5 days per week) and three separate internal implantation radiotherapy treatments to the vagina. Internal implantation treatments are usually given once a week during the course of external beam radiotherapy.

Moderately advanced cervix cancers (FIGO stage IB, II, or IIIA) are usually  treated with a combination of radiation therapy and chemotherapy (medication that helps to cure the cancer). Chemotherapy is usually given as an intravenous injection every 3 weeks during radiotherapy. In most cases the radiation therapy involves 5 weeks of external beam radiotherapy (treatments given 5 days per week) followed by two internal implantation radiation therapy treatments with tandem and ovoid applicators. The patient stays in a private room in the hospital for approximately 3 days with each internal implantation treatment. The two internal implantation procedures are separated by 1 or 2 weeks. Therefore, radiation therapy for this stage of cervix cancer usually takes a total of 8 to 10 weeks to complete both external beam and internal implantation portions of the radiotherapy program.

Advanced-stage cervix cancer (FIGO stage IIIB or IV) is usually treated with a combination of radiation therapy and chemotherapy. The exact schedule of radiotherapy depends on multiple factors. Some patients receive a program involving 5 weeks of external beam radiation therapy with treatments given twice a day, 5 days per week. Following the completion of external beam radiotherapy, 1 or 2 internal implantation procedures are done depending on the extent of the cancer. A variety of internal implantation techniques are used. Some patients receive internal implantation radiotherapy with a tandem and ovoid applicator as described above; other patients require different approaches.

Uterus

Cancer of the uterus is usually treated with surgery (a hysterectomy). The need for radiotherapy depends on multiple factors such as the health of the patient, the growth pattern of the cancer, the extent of the cancer in the uterus, and the presence of cancer in pelvic lymph nodes. When radiation therapy is necessary after a hysterectomy, most patients are treated with a combination of 5 weeks of external beam radiotherapy (5 treatments each week) and three internal radiotherapy implantation treatments to the vagina. Internal implantation treatments are done once a week for 3 consecutive weeks. Internal implantation radiotherapy in this setting is given on the same day as an external beam radiotherapy treatment so the entire course course of radiotherapy treatment takes 5 weeks. Internal implantation procedures are done in the radiation oncology clinic. Each internal implantation session takes about 45 minutes. The patient does not need to stay in the hospital after the internal implantation treatment. Anesthesia is not used during the procedure because there is usually little discomfort.

Vagina

Very small tumors of the vagina may be treated with either surgery or radiation therapy. In most cases radiation therapy is the best treatment because the surgical procedure that would be needed to cure the cancer would require removal of too much normal tissue. The radiation therapy program for vaginal cancer usually involves 5 weeks of external beam radiation treatments (treatments given 5 days per week) followed a few weeks later by a 3 day radiation treatment with internal implantation. Patients go to the operating room with anesthesia for the internal implantation procedure. The basic implantation technique usually involves inserting multiple needles into the area of the vagina involved with cancer. Radioactive wires are then placed in the needles to deliver radiation treatments. Patients stay in a private hospital room for the 3 days of internal implantation therapy.

Ovary

All patients with ovarian cancer undergo surgery to remove as much of the cancer as possible. Most patients are treated with chemotherapy. Radiation therapy is used in selected cases when the cancer has responded well to prior treatment, but there is still a high risk of tumor recurrence.

At the University of Florida radiation therapy for ovarian cancer is given in two different ways. Patients with no evidence of cancer after initial surgery and chemotherapy may be treated by infusing a radioactive liquid called P-32 into a part of the abdomen called the peritoneal cavity. P-32 treatment is unusually done in a hospital room. During instillation of P-32, side-effects are usually limited to a feeling of fullness in the abdomen that goes away after a few hours.

Patients who respond well to surgery and chemotherapy, but are not suitable for P-32 treatment, are usually treated with external beam radiation treatments. The whole abdomen is treated with radiotherapy so treatment in this setting is called whole abdomen radiotherapy. The University of Florida has been using an innovative schedule of whole abdomen radiotherapy for many years with good results. Patients come for radiation treatments twice a day, 5 days per week (Monday through Friday), for approximately 5 weeks. Side-effects usually include a feeling of being tired, loss of appetite, and possibly nausea and diarrhea. Medications are used to prevent nausea, and most patients have little difficulty with whole abdomen radiotherapy.