What are the risk factors for getting ovarian cancer?

Ovarian cancer is often detected late (stage III and IV) since we do not have effective screening test for it.  As a result, many patients with ovarian cancer died from the disease.  Some of my patients and their family ask me about risk factors that may increase their of ovarian cancer.  These risks may include

• Older age: ovarian cancer is thought to arise from frequent ovulation.  More ovarian ovulation results in more damage-repair of ovarian cell layer.  Some of the cells may mutate into cancer with time.  Thus, older age is the main risk factor for ovarian cancer
• Having one or more relatives with ovarian cancer: you may have BRCA genes or other genes that may make you susceptible to cancer.
• Having abnormalities in a gene, called BRCA1 or BRCA2.  BRCAs are tumor suppressor genes.   These genes make proteins that monitor and suppressor mutation which then lead into cancer.
• Having genes that are linked to hereditary nonpolyposis colorectal cancer (also called Lynch syndrome).  This mismatch repair genes responsible to multiple cancer mutations that lead to cancers in ovary, colon, uterus, etc.
• Never being pregnant: that means you ovulate more.
• Being overweight: may relate to excess estrogen level.

Some factors can reduce your risk of developing ovarian cancer, including:

• Using hormonal methods of birth control (pills, patch, vaginal ring, injection): these reduces the number of ovulation.  Some studies suggest 50% reduction in ovarian cancer by taking birth control for a few years.
• Being pregnant, breastfeeding: reduce your life time number of ovulation
• Having your tubes tied to prevent pregnancy: we think this is related to detecting any abnormalites/precancerous lesion during the tubal ligation procedure or some other unknown effect.
• Having your uterus or ovaries removed: self explanatory.  Although you may not get ovarian cancer since your ovaries have been removed, but you may still get peritoneal cancer (similar cells to your ovary that line entire internal abdominal and pelvic cavities).

excessive sugar may decrease your life and increase risk of cancer

There have been some interesting observational studies about excess calorie/sugar intake that correlates caloric restriction with longer life span.  Most of these studies were in animals such as mice.   Another observation was during the great depression, average life span was increased by 6 years than what expected - postulated to decrease food intake (except those stories about people committed suicide after losing their life saving in stock market).  

 

One common factor in animal and human studies was a protein called IGF1 (insulin growth factor 1) which is increased in response to our eating.  IGF1 seems to promote cell growth which is important in cell repair but excess of it may also induces cancer growth.

 

The fastest way to reduce IGF1 is by fasting.   I do not recommend fasting unless you are under your doctor's supervision.  However, I suspect that reducing overall amount of calorie/sugar intake will reduce excess IGF1 production.  Sugar/calories were hard to come by when we were roaming in the African prairie million of years ago.  Now, you just have to stop at your gas station and get a large cup of soda.  

 

My patients often told me that they do not eat much - in fact some of them just eat once or twice a day.  However, when I reviewed their food diary, we found that they ate mostly the wrong things (high calorie food).  My recommendation is to discuss with your physicians on how much calorie should you eat per day and stick to it.   In general, we eat more calories than we should.

PS: please read on my previous blog about exercise as well.  I am convinced that eating less calorie and more exercise are the most mundane advice I could give you but also the most effective in getting you healthier and live longer.

How do I treat my anemia during chemotherapy

Anemia (low red blood cells) have many causes.  During chemotherapy, it is usually due to suppression of your bone marrow (organs that make red blood cells).  Cancer also releases chemicals (cytokines) that can suppress your kidney from making erythropoetin (protein that induces your bone marrow to produce red blood cells).   In most of my patients undergoing active chemotherapy, iron deficiency anemia is not common.

Most anemias from cancer or chemotherapy are treated with blood transfusion.  Blood transfusion can rapidly replenish your blood and make you feel better quickly.  But blood transfusion has risks such as transfusion reaction, infection (HIV, hepatitis, etc) and others.   With advancement of testings, blood transfusion risks have decreased markedly.   In some selected cases, artificial erythropoetin may be given.  There are some studies that suggest giving erythropoetin may induce blood clot and cancer growth.  Thus, discuss with your oncologist before hand.

Reference:

- Santoso JT. Saunders B, Grosshart K.  Massive blood transfusion in obstetrics & gynecology.  Obstet Gynecol Surv. 2005 Dec;60(12):827-837

- Santoso JT. Lin D, Miller DS. Transfusion medicine in obstetrics and gynecology. Obstet Gynecol Surv 50(6): 470-481, 1995

Shingle affecting your face could cause blindness

Varicella-zoster virus (VZV) infection causes two clinically different types of disease. First, the primary infection with VZV results in varicella (chickenpox).  Chicken pox is characterized by vesicular lesions in different stages of development on the face, trunk, and extremities. The second manifestation is herpes zoster, also known as shingles, results from reactivation of  old VZV infection within the sensory nerves. The symptoms of herpes zoster are painful blister lesions on one side of your body, which usually occurs in a restricted dermatomal distribution.  Herpes zoster is not the same thing as having the sexually transmitted herpes infection.

Herpes zoster/shingle is usually not common in immunocompetent  adults than in patients with immunosuppression,  such as having HIV or undergoing chemotherapy.   Please let your doctor knows right away if you start to have painful skin blister.   Especially important is if you have these painful blister around your face and tip of your nose (the Hutchingson's sign).  In some cases, the inflammation could affect your eyes (herpes zoster ophthalmicus) and may cause blindness.  In general, you are then admitted to the hospital for intravenous antiviral treatment and an ophthalmologist often is consulted to check your vision and optic nerve.

Please see also my blog on Shingle and Chemotherapy, posted previously on November 8, 2012

Vaginal bleeding after hysterectomy

After hysterectomy (removal of uterus and cervix), you may have occasional vaginal spotting.   This is usually due to the healing process in the vaginal cuff.   During hysterectomy, your surgeon has to cut part of your vagina and suture it back.   The blood could be dark from old blood or it could be bright red from acute bleeding.   Although most post-hysterectomy vaginal bleeding is not usually life-threatening, you should always call your doctor if the bleeding is more than just spotting or if you have any concerns.   

In the office or emergency room, pelvic exam is usually done.  If the bleeding is due to old blood from surgery that clotted and then hemolyze, there is not much need to be done.  If the bleeding due to the healing vaginal cuff, your doctor may cauterize it with silver nitrate (minimal pain).  However, if the bleeding is significant amount and continuous, then you may be taken back to the operating room.  

I completed my chemotherapy, how do I know that my cancer has not recurred?

In gynecologic cancers (uterine, ovarian, fallopian tube, peritoneal, cervical, vulvar and vaginal cancers), we usually recommend follow up visit every 3-6 months after completion of your surgery and/or chemo and/or radiation therapy.   This 3-6 months check up usually suggested for the first 2 years after completion of your therapy because most cancer recurrences occurred in the first 2 years.   From year 3 to 5 after treatment, I usually follow up on my patients every 6-12 months.  After 5 years, I usually discharge the patient from my practice since cancer recurrence after 5 years of follow up is rare.

The most important test during follow up is history and physical exam.  As my old mentor taught me that 80% of diagnosis could be achieved by just talking to patients.  This is why your diary of complaints or concerns are very important in helping your doctor to diagnose your ailments.   I love it when my patients come with a written list of concerns and questions.

Based on history and exam, I then decide whether to order CT scan or MRI or other tests.   The only tumor marker that helpful to order is for ovarian, fallopian tube, peritoneal and some very advanced uterine cancers.   Even this practice of ordering tumor marker (CA125) has been questioned by a randomized trial that I discussed in my earlier blog.  For cervical cancer, the SGO guidelines recommend only once a year pap smear.  There are some different opinion on this pap smear guideline as well among experts.

So, do bring your list of written questions and concerns to your doctor visit.   Remember that a short pencil has much better recall than a long memory.

HPV testing for cervical cancer screening

Although cervical cancer is the 2^nd highest cancer in women in the world, its number has decreased markedly with advancement of cervical cytology (pap smear).   In the last a few years, HPV (Human Papilloma viruses) testing has been promoted to reduce the number even more with less frequent of doctor visit.

The current recommendation is to start pap smear at age 21 years old.  From age 21 to age 30 years old , pap smear should be done every 3 years.   You still need to come for pelvic exam yearly.   From age 30 to 65 years old, your doctor may recommend pap smear every 3 years or contesting (pap smear and HPV testing) every 5 years.   Younger people tends to be more sexually active, thus, having more HPV.  Fortunately, most of HPV infections go away on their own.  This is the reason on not testing women younger than age 30 years old. 

There are some fears that changing the frequency of pap smear from yearly to every 3 -5 years may miss some cancers.  Unfortunately, we do miss cancer.  But the risks of doing pap smear annually seems to be greater than every 3-5 years: excess procedures, cost, etc.

The pap smear guideline continues to change.  Thus, discuss it with your health care providers.

Risks for anal cancer

Cervical cancer share the same cause as most anal cancer: namely HPV viruses.   Thus, it is reasonable to be concerns.   Our study done at the West Clinic has just been published in August 2013 at the Obstetrics & Gynecology journal.   

We studied 327 patients with a biopsy-confirmed diagnosis of genital intraepithelial neoplasia (vulvar, vaginal, or cervical) underwent both anal cytology and anoscopy. We identified 64 (46.7%) women with anal intraepithelial neoplasia (which may lead to anal cancer), yielding a prevalence of 19.6%. Immunosuppression, vulvar dysplasia, multiple sexual partners (more than four), smoking history, and history of anal sex were positively associated with anal intraepithelial neoplasia (P<.05). 

We develop a simple predictive model based on the presence or absence of two of three risk factors (VIN, immunosuppression, and history of anal sex).  If you have two out of these 3 risk factors, please discuss with your health care providers about screening test for anal cancer.   

Reference:  Elnaggar AC, Santoso JT.  Risk Factors for anal intraepithelial neoplasia in Women with genital dysplasia.  Obstet  Gynecol .  2013, 122: 218-223