Ovarian cancer: state of the art and future directions

The median survival of patients with ovarian cancer has increased steadily, mainly due to a multidisciplinary approach including surgery and chemotherapy. This editorial article summarizes the important messages taken from clinical research performed in this field over the last 15 years. It deals with the following issues: screening, prevention, management of early and advanced disease, maintenance/consolidation therapies and the treatment of relapsing patients. It also gives some future directions with the hope to improve the management and the outcome of this highly lethal disease.     

Cervical cancer screening at Ibadan

Over a period of 44 months, 3171 smears were performed at the University College Hospital (UCH). Ibadan, Cytology Clinic. Of these, 44.2% were in asymptomatic women. Fifty-five point three percent were normal; 15.6% of the smears were reported as non-specific inflammatory changes while 20.1% were due to specific infections. Varying degrees of cervical intra-epithelial neoplasia (CIN) were diagnosed in 8.4% of the smears. The abdominal smears were treated with chemotherapy, cryocautery, diathermy, cone biopsy and hysterectomy. A simplified management plan for a patient with an abnormal smear based on our experience is also presented.     

Cervical cancer prevention--cervical screening: science in evolution

The incidence and mortality of cervical cancer in the United States has declined by more than 70% since the 1950s. This decline is attributed mainly to the introduction of Papanicolaou's test in the 1940s. Cervical cancer, however, remains the second most frequent of all female malignancies worldwide, with 80% of the cases occurring in resource-poor countries. This disparity is attributed primarily to the lack of screening and treatment of precancerous lesions. This article describes the traditional methods of screening for cervical cancer and innovative methods that might help overcome financial and cultural barriers to more widespread screening.     

Cervical cancer screening in developing countries

In developing countries, cervical cancer remains a clinical problem of public health proportions. Eighty percent of the approximately 400,000 new cases of cervical cancer each year occur in such settings. Primarily as a result of the introduction and success of screening programs, cervical cancer rates in developed countries have dropped remarkably. However, in most developing countries, screening programs are virtually nonexistent. Reasons for this relate primarily to lack of public awareness and the fact that screening via cytology is an untenable proposition for mass screening in such low-resource settings. Matching the resources available to provide cervical cancer screening in such settings requires alternative means of providing testing and treatment. Recent evidence indicates that, depending on local conditions and locally-made decisions, visual inspection of the cervix with acetic acid wash, coupled with a benign form of therapy, such as cryotherapy, could hold promise as a means of testing and treatment. By adapting resource-appropriate technologies and building local consensus regarding clinically driven public health approaches that are safe and feasible, the challenge of reducing the mortality from cervical cancer in developing countries can yet be met.     

Sentinel lymph node biopsy in breast cancer: state of the art

Axillary lymph node excision of level I and II with at least 10 lymph nodes is the operative gold standard for invasive breast cancer. Axillary lymph node excision is a diagnostic procedure for histopathologic tumor classification, for assessment of prognosis, local tumor control and adjuvant therapy decision. The sentinel node biopsy is a minimal-invasive procedure to determine the axillary lymph node status by excision of one or more sentinel nodes. This procedure is being increasingly implemented in breast cancer surgery. The classical axillary lymph node excision can be replaced by sentinel node biopsy if sentinel nodes are free of invasion in the intraoperative as well as in the final histopathological report. Sentinel node biopsy can become an operative routine procedure only in a quality-controlled environment.     

Cervical cancer prevention using visual screening methods

Although cervical cancer is only the fifth leading cause of cancer deaths in women globally, it remains the leading cause of cancer deaths among women in developing countries. The approach to cervical cancer prevention used in developed countries has failed in most of the world because widespread Pap smear screening and the evaluation by specialists of women who screen positive is expensive and requires an infrastructure that is not easily sustainable in most developing countries. Over the last decade, investigators have explored alternative strategies for cervical cancer prevention that may be easier to implement in developing countries. These include HPV DNA (human papillomavirus DNA) testing, cervicography, and direct visualisation techniques.¹ Of these, direct visual inspection has received the most attention because it is thought to be the least expensive and to have the greatest potential for screening and treatment in one visit. Multiple studies have now evaluated visual screening methods in developing countries. However, presumptions that parameters of effectiveness in controlled research settings can be projected to mass screening programmes may have inherent fallacies. We believe caution is needed when introducing a new approach to screening that could lead to overtreatment of large numbers of women without disease, in efforts to capture and prevent all disease. This paper examines the implications of the expanded use of direct visual inspection (DVI) for screening or diagnosis, raising the difficult question of risks and benefits when treating many to save a few.     

Cervical cancer screening in Poland and worldwide

High cervical cancer morbidity remains an unresolved epidemiologic problem in Poland. Prevention programs used in the past years did not lead to significant decrease in cervical cancer mortality and morbidity. Countries that introduced active prevention programs several decades ago achieved significant decrease by up to 80%, in the cervical cancer morbidity. We present in this paper the principles of the screening program introduced in Poland in 2006 and compare it with the screening models applied in the other countries. The special attention is drawn to the age at which screening is commenced and stopped as well as to the screening intervals. Advantages and disadvantages of the PAP smear are discussed in great details. Additionally the potential role of HPV DNA testing is discussed, including the possibility of replacement of cytological tests with HPV testing.     

Cervical cancer screening in England and Wales: an update

The National Health Service Cervical Screening Programme in England and Wales has been a significant factor in the fall of mortality in cervical cancer in England and Wales. This improvement is likely to reach a plateau. There appear to be two approaches to combat this. Firstly, and most importantly, coverage rates need to be improved. Secondly, the method of screening can be improved. This review article aims to look at changes that are currently being considered in order to further improve the Programme, whilst keeping it as cost-effective as possible. From a technical point of view, these include the introduction of liquid-based cytology and human papilloma virus (HPV) testing as well as other new technologies. Also discussed are the issues of the management of mildly dyskaryotic smears by cytological surveillance or immediate colposcopy, the auditing of all previous smears of patients with cancer of the cervix, and a possible change in the nomenclature used in England and Wales towards the Bethesda system (TBS). The psychological morbidity of screening is also considered as reducing this may improve coverage.     

HRT: state of the art]

Hormone replacement therapy (HRT) in postmenopause represents the most advanced frontier of preventive medicine in a rapidly evolving society that aims to emphasise, today as in the past, the leading role of women. While modern medicine has extended the average life expectancy of women today, it is now the task to enhance the quality of these extra years. HRT prevents cardiovascular disease, osteoporosis, disorders relating to changes in pelvic connective tissue and genitourinary tissues, and it can also have a positive influence on the psycho-affective sphere and, perhaps, alterations in cognitive capacity. Cultural delays and alternate phases of optimism and alarm are not always backed by solid scientific knowledge. Epidemiological research over the past years has underlined the oncological risk of using estrogens, even if associated with progestin, without the necessary methodological clarity and efficacy. From the data reported in the international literature and on the basis of over ten years experience accumulated at Department B of Gynecology and Obstetrics of Turin University, it appears that the oncogenic risk in women taking HRT is not significantly higher if the indications are strictly respected and, when necessary, progestin is associated with estrogen.     

Standard treatment in advanced ovarian cancer in 2005: the state of the art

Abstract.   Bookman MA. Standard treatment in advanced ovarian cancer in 2005: the state of the art. Int J Gynecol Cancer 2005; 15(Suppl. 3): 212–220.
What are standards? The oncology community expends considerable effort to review the results from definitive treatment studies and define recommendations for future studies, as well as standards of care for the community and patients who are not participating in clinical trials. This is a thoughtful and well-intentioned process but subject to considerable bias due to limitations in the data and/or their interpretation. While ovarian cancer is highly responsive to platinum-based therapy after initial cytoreductive surgery, there is a substantial risk of recurrence, which is accompanied by the emergence of drug-resistant disease. Better treatments with improved long-term outcomes are needed. From this perspective, standards can help to provide a baseline for assessing gaps in our current knowledge and defining priorities for future clinical trials. While not an exhaustive review, this study will focus on key clinical concepts that are guiding ovarian cancer research and treatment.     

Emergency contraception: the state of the art

Emergency contraception, otherwise known as post-coital contraception, is part of the continuum of contraceptive methods that women and couples can use for pregnancy prevention. Although emergency contraception should not be used as a regular, plan-ahead contraceptive method, it gives a woman one last-ditch effort to prevent unwanted pregnancy. This paper reviews the history of emergency contraception, the need for further studies, and results of studies conducted at the World Health Organization. Various methods used for emergency contraception are discussed, as well as their efficacies and side effects.     

HELLP syndrome: the state of the art

Preeclampsia/eclampsia has been recognized for centuries and continues to plague both the patient and the obstetrician. A severe variant, the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP), has been recognized for 50 years. Although much new data has been elucidated about the condition, only several observations have withstood the test of time. These are the uniqueness of the disease to humans, the progressive nature of the disease, and the fact that delivery is the sole therapy. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to outline the history of HELLP syndrome and describe the pathophysiology of HELLP syndrome, to summarize the clinical presentation and differential diagnosis of HELLP syndrome, and to list the various management options.     

Micro-RNAs and ovarian cancer: the state of art and perspectives of clinical research

Dysregulation of microRNA (mi-RNA) expression plays a major role in the development and progression of most human malignancies. Members of the miR-200 family, miR-182, miR-214 and miR-221 are frequently up-regulated, whereas miR-100, let-7i, miR-199a, miR-125b, mir-145 and miR-335 are often down-regulated in ovarian cancer compared with normal ovarian tissue. Most mi-RNA signatures are overlapping in different tumor histotypes but some mi-RNAs seem to be histotype specific. For instance, the endometrioid type shares with the serous and clear cell types the up-regulation of miR-200 family members, but also presents over-expression of miR-21, miR-202 and miR-205. Clear cell carcinoma has a significantly higher expression of miR-30a and miR-30a*, whereas mucinous histotype has elevated levels of miR-192/194. In vitro and in vivo investigations have shown that several mi-RNAs can modulate the sensitivity of ovarian cancer to platinum and taxane, and clinical studies have suggested that mi-RNA profiling may predict the outcome of patients with this malignancy. Some mi-RNAs could be used as biomarkers to identify patients that might benefit from the addition of molecularly targeted agents (i.e. anti-angiogenic agents, MET inhibitors and poly(ADP-ribose) polymerase (PARP) inhibitors) to standard chemotherapy. Moreover, mi-RNAs could represent potential targets for the development of novel therapies.