A global study in 2019 showed that 36.3% of cancers in women are caused by behavioral, environmental, occupational or metabolic risk factors. Smoking is a major risk factor. Other risk factors include alcohol, high basal metabolic index and unsafe sex. As we are witnessing a cultural shift, liberalism and westernism, it is up to us to adopt some behavioral and lifestyle choices to make the change better.
Here are some general lifestyle recommendations to reduce the risk of cancer:
● Tobacco – Avoid smoking, chewing or snorting.
● Be physically active
● Maintain a healthy weight
● Eat a diet rich in fruits, vegetables, and whole grains and low in saturated/trans fats, red meat, and processed meat
● Refrain from alcohol
● protection against sexually transmitted infections; this includes vaccination against human papillomavirus (HPV)
● Use sun protection and avoid tanning.
● Get regular check-ups for cervical and breast cancer.
Ovarian and cervical cancers are the most common Gynecological cancer in India and worldwide. In India, cervical cancer is the second most common cancer in women after breast cancer. Gynecological cancers include – cervical, ovarian, endometrial (uterine), vulvar, vaginal and fallopian tube cancers and gestational trophoblastic neoplasia.
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Recognize some common symptoms of gynecological cancer:
⦁ Abnormal vaginal bleeding, whether occurring after menopause or between periods or during unusually heavy menstrual cycles, as well as bloody or foul-smelling vaginal discharge, is common in most gynecological cancers except vaginal cancer.
⦁ Ovarian cancer may cause feeling full easily or difficulty eating, bloating, and stomach or back pain.
⦁ Ovarian or uterine cancer can cause pelvic pain or pressure.
⦁ Frequent urination and/or constipation may be a symptom due to the anatomical proximity of the genital organ to the bladder and rectum.
⦁ Itching, burning, pain or tenderness in the vagina. Apart from this, changes in skin color, rash, wounds or warts are found in vaginal cancer.
Prevention
Vaccinations and screening tests are the front-line aspects of prevention. Since human papilloma virus (HPV) is a sexually transmitted infection that causes the most cervical, vaginal, and vulvar cancers, HPV Vaccination Plays an important role in its prevention.
The table shows the HPV infections responsible for cancer in different regions.
HPV vaccination schedule
Above is the guidance for HPV vaccination. There are different vaccines available in India, such as bivalent, quadrivalent and nonvalent, namely Cervarix, Gardasil 4 and Gardasil 9 respectively. These can be used as per the schedule shown in the given table.
Screening Tests – Cervical Cancer
These help detect precancerous changes in the cervix, making early detection and treatment possible. Commonly used tests are cervical cytology (Pap test) – the traditional slide test or liquid-based methods. Another is HPV DNA testing. These can be done alone or as a co-test. Visual inspection acetic acid (VIA) testing is also used in low-resource areas such as rural India.
Federation of Obstetrics and Gynecological Societies of India (FOGSI) recommends starting screening at age 25 in well-resourced areas, otherwise at age 30. Cytology testing is recommended every 3 years when done alone. High-risk HPV testing is recommended every 5-10 years when done alone as a primary test. At least twice in a lifetime in areas with limited resources, i.e. at ages 35 and 45. Recommended age to end screening is 65 years with 3 consecutive negative cytology results or 2 consecutive negative HPV results in 10 years. In low-resource areas FOGSI recommends HPV testing or VIA every 3-5 years between the ages of 30 and 65.
The World Health Organization recommends testing between the ages of 30 and 50, and testing frequency should be every 3 to 10 years.
Other risk factors:
The unopposed action of the hormone estrogen is the basis of endometrial cancer.
Lynch syndrome is a genetic risk factor for endometrial and ovarian cancer. BRCA 1 and BRCA 2 variants primarily increase the risk of breast and ovarian cancer
The use of tamoxifen, especially in menopausal women, may increase the risk of endometrial cancer.
Chronic anovulation during the menopausal transition or in polycystic ovary syndrome (PCOS) may be associated with endometrial hyperplasia and progression to endometrial cancer.
Thus, nulliparity and infertility may be risk factors for endometrial cancer. But nulliparity may be protective in ovarian cancer.
Smoking increases the risk of mucinous ovarian cancer.
Obese people have greater changes in endogenous estrogen and insulin resistance, which increases the risk of endometrial cancer. In addition, a moderately increased risk of ovarian cancer is associated with higher BMI.
Early menarche and late menopause increase the risk of endometrial cancer as well as epithelial ovarian cancer.
Age – Germ cell ovarian tumors predominate under age 20, borderline ovarian tumors at age 30 to 40, and epithelial ovarian cancers over age 50. The overall risk increases with age.
The risk increases if a first-degree relative has had endometrial cancer or ovarian cancer.
Protective factors:
One large study found that use of oral contraceptive pills reduced the risk of endometrial cancer by 30-40%. Progesterone-only contraceptives have an even better protective effect.
Pregnancy has a protective effect, number of pregnancies and older age at last birth also play a role in endometrial cancer. Also pregnancy and breastfeeding reduce the incidence of ovarian cancer
Breastfeeding reduces the risk.
Physical activity and diet are beneficial.
With the knowledge of risk factors, symptoms, screening tests and vaccination schedules, it is essential that every woman plays an active role in making lifestyle changes, getting regular check-ups done, recognizing any untoward symptoms and seeking early medical help to reduce the risk of gynecological cancers.
(Author: Dr. Arwa Mohsin E. Senior Consultant Obstetrician & Gynecologist, Fortis Hospital, Richmond Road, Bengaluru)
