In Taiwan, cancer is the top ten causes of death. Uterine cancer, ovarian cancer and cervical cancer are the most common gynecological cancers among women, also ranking within the top ten of Taiwanese women cancers.

        Due to the government cancer screening program, the incidence of cervical cancer has been going down over the years. Women over the age of 30 are eligible to receive an annual Pap smear screening test. Because of the Pap smear screening program, early detection and treatment of precancerous lesions, the incidence of cervical cancer has gradually decreased.

        In addition to the Pap smear, human papilloma virus (HPV) testing is also a kind of cervical cancer screening test. Most cervical cancers are related to HPV infection, but most of them are asymptomatic after infection. The HPV test can check whether high-risk HPV types are found in cervical cells.

Unlike cervical cancer, the incidence of uterine cancer and ovarian cancer have not decreased over the years. Uterine cancer and ovarian cancer do not have standard screening tools. According to the Taiwan Cancer Registry Center data, women aged between forty-five to sixty-five years old are the most common age group for uterine cancer, and there is a trend toward the younger age. Uterine cancer can be divided into endometrial cancer and malignant uterine sarcoma. The most common type of uterine cancer is endometrial cancer.

The most common symptom of endometrial cancer is abnormal vaginal bleeding or postmenopausal bleeding. Although most causes of postmenopausal bleeding are due to benign lesions, but endometrial cancer can also be the cause. If early investigations are performed for postmenopausal bleeding, most of the cancers are found in the early stage. The prognosis of early endometrial cancer is excellent, and the curative rate is also very high. The five-year survival rate for stage I of endometrial cancer is as high as ninety percent. Therefore, I would like to appeal to the public, please don’t think as "rejuvenation" when bleeding after menopause, and should seek medical attention as soon as possible for further examination and treatment.

According to the 2020 National Cancer Registration Report released by the National Health Administration, ovarian cancer stands the top seventh of Taiwanese women deaths, and the seventh most common cancer among Taiwanese women. The normal ovarian position is in the pelvic cavity and it cannot be palpated by ourselves. When you can feel it on your abdomen, the tumor is already very large. The symptoms of early ovarian cancer are not specific and often similar to gastrointestinal symptoms, hence most ovarian cancers are diagnosed in an advanced stage.

The blood test we usually perform during health care examination for ovarian cancer is CA-125, but there are many reasons that will influence the CA-125 value, and some ovarian cancers do not have elevated CA-125 values. Hence CA-125 cannot be used as a screening tool for ovarian cancer. Therefore, if middle-aged women have lower abdominal discomfort, unexplained gastrointestinal symptoms, or abdominal distension, they should come to the gynecological clinic. We can provide pelvic examination and ultrasonography to exclude any abnormal masses in the ovaries. Further investigations can be arranged for diagnosis and treatment if an abnormal pelvic mass is identified.

Introduction of Gynecological Cancer Treatment

In recent years, the treatment of cancer has been progressively improved, and in gynecological cancer as well. Gynecological cancer treatment includes surgery, chemotherapy, radiation therapy and immunotherapy, etc. Here, we would like to introduce some new techniques and treatment of gynecological cancer in our Far Eastern Memorial Hospital. 

I.  Intraperitoneal Chemotherapy

Traditionally, chemotherapeutic agents are administered intravenously. Intraperitoneal chemotherapy is that chemotherapeutic agents are infused directly into the abdominal cavity, allowing the drug to directly contact the tumor cells and then the remaining drug is absorbed into the body through the peritoneum barrier. The drug concentration in the peritoneal cavity will be 20-1000 times that in the blood. Theoretically, the longer the contact time between chemotherapeutic drugs and tumors, the better the local cytotoxic effect. Studies showed it is effective in patients with stage III ovarian cancer with debulking surgery. Some studies have also found that it is also effective for endometrial cancer with abdominal metastasis. In Taiwan, very few medical centers (only two centers) have such a technique. We has reported that the therapeutic efficacy of intraperitoneal chemotherapy is superior than weekly intravenous chemotherapy. 

II.  Sentinel lymph node mapping

Oncogynecological operative procedures include tumor resection and lymph node dissection. But the lymph node dissection would result in surgical complications: such as severe lymphedema of the legs, lymphocele, nerve injury and infection, etc. The sentinel lymph node mapping technique is to identify the sentinel lymph node which is the first node where the tumor drains. When there is lymph node metastasis, the sentinel lymph node is often the first site of lymph node metastasis. Hence, the sentinel lymph node mapping and excision of the sentinel lymph nodes can greatly reduce the side effects related to total lymph node dissection. The utilization of sentinel lymph node mapping technique did not compromise the survival outcome. This technique has been widely used in the surgery of gynecological cancer, such as vulvar cancer, cervical cancer and endometrial cancer. Our oncogynecological team also proved the superiority of sentinel lymph mapping technique. 

III.      Hyperthermic Intraperitoneal Chemotherapy

It is well known that chemotherapeutic agents are given before or after surgery. In fact, there is a technique where a chemotherapeutic drug is given intraoperatively, which is called Hyperthermic Intraperitoneal Chemotherapy (HIPEC). The temperature of the chemotherapy perfusion solution is increased about 42°C and directly infused into the abdominal cavity, using high temperature and chemotherapeutic drugs to kill the cancer cells on the surface. Studies reported HIPEC is effective for ovarian cancer treatment. We mainly used in the treatment of advanced ovarian and peritoneal cancer.

IV.  Intra-operative Radiotherapy

Not only hyperthermic intraoperative chemotherapy, but also intraoperative radiation therapy (Intra-operative Radiotherapy, IORT) can be performed during surgery. After tumor resection, the tumor bed is irradiated directly, which can provide maximal tumor control with irradiation and minimize side effects. This is a new technology of radiation therapy. In gynecological cancer, we have published the feasibility of intraoperative radiotherapy in the treatment of recurrent endometrial cancer and cervical cancer.

V. Precision Medicine

Precision medicine is tailoring the treatment by using molecular testing, such as genes, proteins and metabolic testing, to analyze and compare the human genetic database, to determine the most suitable treatment for individual people to achieve the maximum treatment effect. It is a personalized medicine. Studies have shown that ovarian cancer is related to the loss of homologous recombination repair gene (HRD). Homologous recombination repair gene is one of the important genes of human DNA repair. The BRCA gene is also one of them. In recent years, there is an emerging of corresponding targeted medicine (PARP inhibitors) for the treatment of such patients. Far Eastern Memorial Hospital has the service of genetic testing, including HRD and BRCA gene mutations, and can provide related targeted therapy.

VI. Immunotherapy

The discovery of immune check points PD-1 and CTLA-4 has brought a breakthrough in cancer treatment. By blocking these two immune checkpoints, immune T cells can be activated to kill cancer cells. At present, in gynecological cancer, immunotherapy has been proven to be effective against cervical cancer, endometrial cancer, and ovarian cancer. We also use immune check point inhibitors to treat our patients.

The treatment policies of the gynecological cancer team of Far Eastern Memorial Hospital are patient-centered, continuously improving the treatment of gynecological cancer, and providing high-quality medical care.