Patients at high risk for gynaecological cancer consist of a specific category of patients in which clinical, imaging, and laboratory surveillance may actually be differentiated compared with low-risk patients. The chapter aims to summarize current evidence and recommendations regarding optimal clinical management of high-risk patients for all forms of gynaecological cancer, namely cervical cancer, endometrial cancer, ovarian cancer, and breast cancer. Furthermore, it aims to approach critically the need for estimating cost-benefit of all preventative modalities along with discrepancies in existing guidelines.
TopCervical Cancer
Cervical cancer is one of the most studied gynecological malignancies. It is particularly common in developing countries in Africa and Latin America, and its frequency has declined significantly (up to 60%) over the last few decades in Western countries. Early onset of sexual activity and a high number of sexual partners are factors that increase the risk of cervical cancer. Today it is known that about 99.7% of cases of cervical cancer are due to infection with one of the high risk human papilloma virus (HPV). High risk subtypes 16 and 18 are the most common and are responsible for about 70% of cases. However, the virus alone does not cause cancer, but other risk factors are also required such as smoking, immune deficiency, infection and other viruses and poor nutrition.
Population screening for cervical cancer includes Pap smear cytology test and HPV test. According to the guidelines of the American Society of Colposcopy and Cervical Pathology, women with a medium risk of developing cervical cancer are recommended to have a Pap smear cytology test every 3 years between 21-29 years of age, with an HPV test for women above 25 years of age. In women aged 30-65 years, it is recommended to perform a simultaneous Pap smear and HPV test every 5 years. If this is not possible, a Pap smear test is recommended at least every 3 years. Screening for cervical cancer may be discontinued at 65 years old, if three consecutive Pap smear tests have been negative or if two Pap smear and HPV tests are negative (Saslow et al., 2012).
Women at high risk for cervical cancer should follow closer screening programs. Women at high risk for cervical cancer are those who have undergone a solid organ or bone marrow transplantation, HIV-infected women, women exposed in uterus to diethylstilbestrol (DES), women with personal history of dysplasia or cervical cancer, and women with immune suppression of any etiology (Vegunta, Files, & Wasson, 2017).
Transplantation of a Solid Organ or Bone Marrow
Women who have undergone a solid organ transplantation, especially bone marrow, have a reduced ability to cope with HPV infection. This may be due either to immunosuppressive drugs administered either to prior chemotherapy and/or radiation. Women who have undergone a kidney transplantation have an increased risk of dysplasia in the cervix and anus. They have a 50-fold greater risk of developing vulvar cancer and a 15-fold increased risk of developing cervical cancer. These women are suggested ideally prior to transplantation to perform both Pap smear and HPV testing. They should also be vaccinated against HPV. Post-transplantation should be more regularly screened for vulvar, vaginal and anal cancer by annual gynecological examination. Ideally, a Pap smear and HPV test is recommended every 3 years, and if duplicate testing is not feasible, the annual Pap smear cytology test is acceptable. The purpose of more regular screening is the early detection of low-grade dysplasia and the avoidance of progression to high-grade dysplasia and invasive carcinoma.
HIV Infection
Women infected with human immunodeficiency virus (HIV) are at a higher risk for HPV infection and a reduced ability to cope with immunosuppression. The result is an increased risk for dysplasia of the cervix and cervical cancer. In women with acquired immune deficiency syndrome (AIDS) it is estimated that the average development time of a CIN3 lesion in invasive cervical cancer is 3.2 years, as opposed to 5-7 years for middle-aged women. In HIV-infected women, the first Pap smear cytology test should be performed in the first year after the first sexual intercourse and not later than 21 years, followed by a Pap smear cytology test every 3 years to 29 years of age. In women aged 21-29 years, with a newly diagnosed HIV infection, an annual Pap smear cytology test should be performed. If 3 consecutive examinations are negative, it is recommended to perform a Pap smear cytology test every 3 years. In women aged over 30 years with newly diagnosed HIV infection it is recommended to perform a simultaneous Pap smear cytology test and HPV test at diagnosis. If the results are negative, it is recommended to repeat the double screening every 3 years, and if the HPV test is not feasible, the annual Pap smear cytology test is acceptable. If 3 consecutive tests are negative, the screening can be made every 3 years. Women in this group should perform a Pap smear cytology test after the age of 65 years.