Early Detection of Gynaecological Cancer: Red Flags and BRCA

Early detection of gynaecological cancer depends on three things working together: general practitioners who recognise four red flags, screening and HPV vaccination that stop cervical cancer before it starts, and genetic and molecular tests that identify who is at risk and which tumours will respond to targeted therapy or immunotherapy. Dr. Archit Pandit, Director Surgical Oncology, Fortis Escorts, Okhla, New Delhi, India, treats each as an advance.

Surgery attracts most of the attention in cancer care, but early detection begins in the clinic of the first doctor a woman sees. This article covers the red flags, cervical screening and HPV vaccination, the diagnostic tools now in use, and the targeted therapies and immunotherapies they unlock. The surgical side, from HIPEC to sentinel lymph node mapping, is covered in the article on HIPEC, robotic surgery and sentinel nodes, and the full overview in the complete guide to advanced treatments in gynaecologic oncology.

Four red flags that should prompt a gynaecologic oncology referral

The four red flags are bleeding after menopause, a pelvic mass, an abnormal Pap smear or positive HPV test, and a family history of ovarian, breast or endometrial cancer. There are, in Dr. Pandit's words, hundreds of warning signs he could list, and not everyone would remember them. He asks general practitioners to hold on to four instead, and to act on them at a very early stage.

1. Bleeding after menopause. Any woman who bleeds after reaching menopause should be investigated, because she may be harbouring endometrial (uterine) cancer.
2. A pelvic mass. A mass felt on pelvic examination or seen on ultrasound should never be ignored.
3. An abnormal Pap smear or a positive HPV test. Neither should simply be left alone. High-grade changes, or infection with HPV types 16 or 18, need colposcopy; lower-grade results need repeat testing to confirm that the cervical changes are regressing rather than progressing.
4. A family history of ovarian, breast or endometrial cancer. Any woman, or man, with such a history should consult an oncologist.

Two of these flags lead directly to the tools discussed below. An abnormal Pap smear or HPV result sits within cervical screening; a family history of ovarian, breast or endometrial cancer is the starting point for genetic testing. Dr. Pandit's summary of the whole masterclass was that general practitioners are crucial both for early detection and for getting patients to oncology care in time.

Cervical cancer prevention: HPV vaccination and screening

The best thing about cervical cancer, Dr. Pandit says, is that it is preventable. It is also common in both India and Africa, which he links to similar socioeconomic conditions, a high burden of sexually transmitted infection and a lack of sexual health education among young people.

Prevention works at two levels:

• Screening. His team encourages women to have regular check-ups with Pap smear examination (a sample of cells from the cervix examined for abnormal changes) and HPV testing (a test for the human papillomavirus strains that cause cervical cancer).
• Vaccination. HPV vaccination prevents the infection that causes almost all cervical cancers. His team encourages vaccination especially between the ages of 9 and 26, for both girls and boys.

The HPV vaccines

Two HPV vaccines are the most prominent worldwide: Cervarix and Gardasil. India has since developed its own cervical cancer vaccine, Cervavac. Dr. Pandit describes it as an Indian-made vaccine that is very cost-effective and is licensed for girls and boys from the age of 9 to 26.

The age matters. The vaccine is usually given between 9 and 26, but it is most effective when given between the ages of 9 and 14, before exposure to the virus.

Why general practitioners are central to vaccination

Dr. Pandit wants general practitioners to understand how effective the HPV vaccine is, so that they can be strong advocates for it and build awareness in their communities. He sees great potential for the approach to be replicated in African countries. On his visits to Kenya and Uganda, however, he has found that these vaccines are not widely available. His advice is direct: girls and boys aged 9 to 26 should be vaccinated.

He extends the point beyond cervical cancer. Asked what advances Fortis has made for African patients, he answered that there is nothing particular to African patients, but that there is real scope to spread the use of HPV vaccines against HPV-related oropharyngeal, cervical, anal, penile, vaginal and vulval cancers through forums for African patients and general practitioners. In his view, vaccination is a very important topic of both discussion and practice.

The HPV vaccine schedule, price and screening intervals are set out in detail in Dr. Punyashree R M's guide to eliminating cervical cancer.

Diagnostic advances in gynaecologic oncology

The main diagnostic advances are PET-CT staging, genetic and molecular testing, and artificial intelligence applied to Pap smears and radiology. Dr. Pandit deliberately set aside the routine investigations doctors already know and focused on what has changed.

Imaging: from local assessment to whole-body staging

Transvaginal ultrasound and MRI assess the pelvis. PET-CT goes further: it scans the whole body and shows whether the cancer has spread to any other part of it, which determines the stage of the disease and therefore the treatment plan. PET-CT combines positron emission tomography, which detects metabolically active tissue such as cancer, with computed tomography, which shows anatomy.

Genetic testing: BRCA, HRD, MSI and next-generation sequencing

Several genetic tests now shape gynaecological cancer care. Dr. Pandit named four:

BRCA testing is the test Dr. Pandit singled out for predicting future risk: it tells a doctor which person may go on to develop cancer. This links back to the fourth red flag. A woman or man with a family history of ovarian, breast or endometrial cancer is exactly the person for whom an oncology consultation, and often genetic testing, is appropriate. Next-generation sequencing, he noted, is now performed extensively in India, at five to seven centres.

Artificial intelligence in diagnosis

Dr. Pandit's team has integrated artificial intelligence into Pap smear technology, the radiology department and CT scanning. He sees three benefits: earlier diagnosis, less human error and better support for clinical decisions.

Targeted therapy and immunotherapy for gynaecological cancers

Beyond routine chemotherapy, which he chose not to cover, Dr. Pandit highlighted the drugs that act preferentially on the tumour rather than on the normal cells of the body.

PARP inhibitors for BRCA-positive ovarian cancer

PARP inhibitors are targeted drugs that block an enzyme (PARP) that cancer cells use to repair damaged DNA. Tumours with a BRCA fault already have a weakened repair system, so blocking PARP as well leaves them unable to survive. Dr. Pandit cites PARP inhibitors for BRCA-positive ovarian cancer as a leading example of targeted therapy, and notes that other targeted and immunotherapy drugs are now used in both ovarian and cervical cancer.

Immunotherapy for MSI-high tumours and cervical cancer

Immunotherapy drugs help the patient's own immune system recognise and attack the cancer. Dr. Pandit highlights two settings: tumours that are MSI-high, and cervical cancer, where immunotherapy now forms part of treatment. In his approach to cervical cancer, early disease is treated with surgery, and from stage 2B onwards (when the tumour has spread beyond the cervix into the surrounding tissue) the treatment is chemotherapy with radiation, followed in some cases by immunotherapy.

Availability

His overall message on systemic therapy is that targeted therapy and immunotherapy are advancing quickly and are frequently available in India. His own team has access to both, alongside radiotherapy. For a view of what these treatments cost, see the Jivo Healthcare pages on immunotherapy costs and chemotherapy costs.

Early detection of gynaecological cancer: how the pieces fit

Read together, the advances in this article form a sequence rather than a list. Vaccination prevents most cervical cancers before they start. Screening with Pap smears and HPV tests catches the precancerous changes that remain. The four red flags bring women with possible cancer to an oncologist early. Imaging and genetic testing then define the stage of the cancer and its molecular profile, and that profile decides whether a patient benefits from a PARP inhibitor, immunotherapy or another targeted drug.

For doctors in Africa, Dr. Pandit's practical offer is to help at any point in that sequence, through virtual consultations and second opinions, referral, or observerships that include the team's tumour board. The detail of those routes is in the complete guide, and doctors' own questions to him are answered in the Live Discussion.