Overview of Gynaecological Cancers

Gynaecological cancers are the cancers of the female reproductive tract: the cervix, the endometrium and uterus, the ovaries, fallopian tubes and peritoneum, the vulva and vagina, and gestational trophoblastic disease after pregnancy. The main ones, cervical, endometrial, ovarian and vulvar cancer, each have a distinct cause, a distinct early warning sign and a distinct first test.

Dr. Punyashree R M, a consultant gynaecological oncosurgeon and robotic surgeon at Fortis Hospital, CG Road, Bangalore, focuses on three kinds: the cancers that are very common, those rising in incidence worldwide, and those that can be prevented rather than treated. That framing matters for any doctor who sees women before an oncologist does. Cervical cancer is largely preventable. Endometrial cancer is climbing with obesity and diabetes. Ovarian cancer still presents late in most women. Vulvar cancer is rare, but patients often keep its symptoms hidden. Each has its own early signals, and recognising them is where outcomes are decided.

Who is at risk of gynaecological cancer?

Anybody can develop cancer, and family history explains less of it than many patients assume. Cancer is a large group of diseases in which cells divide, grow and spread without control because of mutations acquired over time. Dr. Punyashree described it as the second highest cause of death and illness worldwide, with incidence expected to rise by about 60% over the next two decades.

Her point on risk was blunt. The old pattern, in which certain cancers belonged to children and others to the elderly, has largely broken down, and almost any cancer is now seen at almost any age. Age still raises risk because mutations accumulate, and in her figures 86% of cancers are seen in people over 50.

Only 5 to 15% of people with a malignancy have a family history of cancer. The larger share is sporadic, and Dr. Punyashree attributes much of it to lifestyle.

The main types of gynaecological cancer at a glance

Each of the major gynaecological cancers has a distinct cause, a distinct early warning sign and a distinct first test. The table below sets out the points Dr. Punyashree treated as decisive for each.

Cervical cancer: the cancer that can be eliminated

Cervical cancer is the most common gynaecological malignancy in developing countries and the fourth most common cancer in women worldwide, with more than 600,000 new cases a year and more than half that number of deaths. It is also, in Dr. Punyashree's words, the only cancer that can be eliminated worldwide, because its cause is known and its precursor stage can be found and treated. HPV vaccination at 9 to 14 years, screening with Pap smears and HPV DNA tests, and treatment of precancerous lesions together close off almost every route to invasive disease. The full prevention, screening and stage-by-stage treatment pathway, including the vaccine schedule and what HPV vaccines cost, is set out in cervical cancer screening, the HPV vaccine schedule and vaccine prices.

Endometrial cancer: the fastest rising

Endometrial cancer is the fastest rising of the gynaecological cancers. Dr. Punyashree said its incidence has doubled in two decades and is expected to rise by a further 50% by 2044, driven by fast food, obesity, diabetes and hypertension. Its signature symptom is postmenopausal bleeding, and its first test is a transvaginal ultrasound measuring endometrial thickness. Diagnosis, the precancerous lesion seen in women undergoing IVF, molecular classification and surgery are covered in endometrial cancer and the 4 mm endometrial thickness rule.

Ovarian cancer: the silent killer

Ovarian cancer earns its name because it produces few early symptoms. About 75% of ovarian cancers are found at an advanced stage. The early clues are vague: bloating, gastritis and early fullness after eating that last more than two weeks and do not respond to medication. Tumour types, risk reduction through tubal surgery, the choice between primary and interval surgery, HIPEC and fertility-sparing surgery are covered in early ovarian cancer symptoms and fertility-sparing surgery.

Vulvar cancer: rare, and often concealed

Vulvar cancer is the one major gynaecological cancer covered in full in this guide, in the section below, because its main obstacle is not biology but delay.

Vulvar cancer: symptoms, diagnosis and treatment

Vulvar cancer is a rare malignancy of the external genitalia that mostly affects older women, and its most common symptom is persistent genital itching. Dr. Punyashree's patients are usually over 60, and many are in their eighties when the disease is found.

Why diagnosis is delayed

The most common symptom is persistent itching in the genital area. Other signs include bleeding, lumps or bumps, a change in skin texture or colour, ulcers, and pain or tenderness that can extend to the groin. The difficulty is disclosure. Many women find the symptom too embarrassing to mention, even at home, and so do not seek help. Dr. Punyashree described the condition as deeply debilitating for exactly that reason: the disease advances while the patient stays silent. For a clinician, the practical lesson is to ask older women directly about vulvar itching and skin changes, and to examine.

Risk factors include HPV infection, smoking, advanced age, a weakened immune system, and genetic and environmental factors.

How vulvar cancer is diagnosed

Diagnosis starts with the history and a careful examination. Where needed, the team performs vulvoscopy (magnified examination of the vulva) together with colposcopy of the cervix and vaginoscopy, because HPV-related disease can affect all three sites. Biopsy sites are chosen after applying acetic acid, or toluidine blue followed by an acetic acid wash, which highlight abnormal areas. As in the cervix, squamous cell carcinoma is the most common type. MRI or CT is added where the extent of disease needs to be defined, and the cancer is then staged.

Treatment: a shift towards conservative surgery

Surgery for vulvar cancer has become markedly less mutilating. The older radical operation, removal of the vulva together with both groins through a single wide "butterfly" incision, carried heavy morbidity. Dr. Punyashree's team now performs radical or modified radical vulvectomy with unilateral or bilateral inguinal lymph node dissection, tailored to where the tumour sits, how large it is, and whether it is central or lateral. For a very small tumour, a simple vulvectomy or a wide local excision can be enough.

The groin dissection has been the main source of complications. Conventional inguinal lymph node dissection frequently leads to wound breakdown and seroma (a collection of fluid under the wound). Her team performs video endoscopic inguinal lymphadenectomy (VEIL) with the robot, removing the groin nodes through small ports, and she reported that robotic assistance has reduced these complications.

Some women are treated with radiation or chemoradiation instead of surgery, depending on stage, and adjuvant therapy may follow surgery. When a tumour is too large to remove with a clear margin, neoadjuvant chemotherapy is given first to make it operable.

Sentinel lymph node mapping: the technique step by step

Sentinel lymph node mapping identifies the first lymph node that drains a tumour, so that it can be removed and examined in place of a full lymph node dissection. Dr. Punyashree uses it in endometrial cancer and in early stage cervical cancer, with indocyanine green (ICG), a fluorescent dye, and the near-infrared Firefly imaging mode on robotic or 4K laparoscopic systems.

Her sequence is deliberate:

1. Open the retroperitoneal spaces first. Identify the external iliac vein and open the obturator spaces, so that the field is ready before any dye is injected.
2. Inject ICG into the cervix at the 3 o'clock and 9 o'clock positions.
3. Wait 5 to 7 minutes, then switch on the Firefly view. The team can complete another step of the operation while waiting.
4. Remove the first node to glow. In her experience this is most often in the obturator group.
5. Send the node to an experienced oncopathologist for frozen section (rapid analysis while the operation is under way) and ultrastaging, a sectioning technique designed not to miss micrometastases.

The order matters. A common error is to inject the dye and then begin opening the retroperitoneum. If that dissection bleeds, the glowing node becomes hard to locate. Dissecting first and injecting second avoids the problem.

Dr. Punyashree also set a clear rule for centres adopting the technique. Before relying on it, a centre should run a pilot of at least 25 cases each of endometrial and cervical cancer in which the sentinel node is mapped and a complete lymph node dissection is then performed. The pilot tests two things: whether the surgeons reliably find the true sentinel node, and whether the pathologist reports it correctly. A negative sentinel node with a positive node elsewhere in the full dissection shows that the true sentinel was missed. Only once both surgeon and pathologist are validated should sentinel mapping become the method of choice.

Nerve-sparing radical hysterectomy: complications and recovery

Bladder dysfunction is the most common complication of radical hysterectomy, and sparing the pelvic nerves keeps it uncommon. A radical hysterectomy removes the uterus with the surrounding tissue (the parametrium) and is used in early cervical cancer; in endometrial cancer that has spread to the cervix, a modified radical hysterectomy is used only where needed to obtain clear margins. Dr. Punyashree's team performs a nerve-sparing radical hysterectomy, identifying the hypogastric plexus and the inferior hypogastric nerve, the autonomic nerves that control the bladder, and preserving them.

In her series, about one or two patients in 100 develop urinary problems after a nerve-sparing operation. The exception is a tumour that infiltrates or adheres to the nerves, where some urinary difficulty is more likely. These patients undergo bladder training, and with good surgery and spared nerves the problem is usually transient.

Pelvic and para-aortic lymph node dissection (removal of the lymph nodes in the pelvis and alongside the aorta), up to level 4, carries an intraoperative risk of vessel injury. Care is also needed around the obturator nerve; if it is injured, it can be repaired with fine sutures and the patient given physiotherapy to recover function. Lymphoedema, the chronic limb swelling familiar after axillary lymph node dissection for breast cancer, is something Dr. Punyashree said her team has not yet seen after its pelvic dissections, although published series report lower-limb lymphoedema in a substantial minority of women after full pelvic lymphadenectomy.

Enhanced recovery after surgery

Her team follows an enhanced recovery after surgery (ERAS) protocol, with deep vein thrombosis prophylaxis, including mechanical compression:

• The patient walks on the day of surgery. A woman operated on in the morning is out of bed by evening or night.
• Clear oral fluids start within 4 hours of surgery.
• A liquid diet starts within 6 hours.

The aim, in her words, is to keep the body's physiological state close to what it was before the operation. When these protocols are followed, morbidity stays low.

For women travelling for treatment, the cost of the operation itself is set out on the radical hysterectomy cost page.

How gynaecological cancers can be prevented

Dr. Punyashree's preference, stated at the outset, is to prevent rather than treat. For three of the major gynaecological cancers, the modifiable steps are clear:

• Cervical cancer: HPV vaccination, regular screening and safer sexual practice.
• Endometrial cancer: weight, diabetes and hypertension control; progestogen protection where oestrogen exposure is high.
• Ovarian cancer: removal of the fallopian tubes when a woman who has completed her family undergoes hysterectomy or myomectomy, and knowledge of family history so that inherited mutations can be found.

Her answers to the doctors on the call, covering imaging where PET-CT is unavailable, HPV vaccine programmes and prices, and molecular profiling where access is limited, are on the Live Discussion page. Her profile is at Dr. Punyashree R M, and related specialists are listed under oncology and obstetrics and gynaecology.