INTRODUCTION

i Cancers can occur in any part of the female reproductive systemthe system vulva, vagina, cervix, uterus, fallopian tubes, or ovaries. These ovaries. cancers are called gynecologic cancers. cancers. iGynecologic cancers can directly invade nearby tissues and organs or spread (metastasize) through the lymphatic vessels and lymph nodes (lymphatic system) or bloodstream to distant parts of the body. body.

I. CANCER OF THE UTERUS

Cancer of the uterus begins in the lining of the uterus (endometrium) and is more precisely termed endometrial cancer (carcinoma). (carcinoma). It is the most common gynecologic cancer and the fourth most common cancer among women. women. This cancer usually develops after menopause, most often in women aged 50 to 60. 60.

Risk factors for endometrial cancer include the following: periods), menopause after age 52, or both

k early menarche (the start of menstrual

k menstrual problems (such as excessive bleeding, spotting between menstrual periods, or long intervals without periods) k never having had children k tumors that produce estrogen k high doses of drugs that contain estrogen, such as estrogen therapy without a progestin (synthetic drugs similar to the hormone progesterone), taken after menopause

k use of tamoxifen k obesity k high blood pressure k diabetes kfamily history of cancer of the breast, ovaries, large intestine (colon), or lining of the uterus.

Many of these conditions increase the risk of endometrial cancer because they result in a high level of estrogen but not progesterone. Estrogen promotes the growth of tissue and rapid cell division in the lining of the uterus (endometrium). Progesterone helps balance the effects of estrogen. Levels of estrogen are high during part of the menstrual cycle. Thus, having more menstrual periods during a lifetime may increase the risk of endometrial cancer.

Tamoxifen a drug used to treat breast cancer, blocks the effects of estrogen in the breast, but it has the same effects as estrogen in the uterus. Thus, this uterus. drug may increase the risk of endometrial cancer. cancer.
 

Taking oral contraceptives that contain estrogen and a progestin appears to reduce the risk of endometrial cancer. cancer. More than 80% of endometrial 80% cancers are adenocarcinomas, which develop from gland cells. cells. About 5% are sarcomas, which develop from connective tissue and tend to be more aggressive. aggressive.

Symptoms and Diagnosis

<Abnormal bleeding from the vagina is the most common early symptom.

One of three women with vaginal bleeding after menopause has endometrial cancer. Women who have vaginal bleeding after menopause should see a doctor promptly. A watery, blood-tinged blooddischarge may also occur. Postmenopausal women may have a vaginal discharge for several weeks or months, followed by vaginal bleeding

If doctors suspect endometrial cancer or if Pap test results are abnormal, doctors perform an endometrial biopsy in their office. This test accurately detects endometrial cancer more than 90% of the time. If the diagnosis is still uncertain, doctors perform dilation and curettage (D and C ) in which tissue is scraped from the uterine lining. At the same time, doctors may view the interior of the uterus using a thin, flexible viewing tube inserted through the vagina and cervix into the uterus in a procedure called hysteroscopy.

If endometrial cancer is diagnosed, some or all of the following procedures may be performed to determine whether the cancer has spread beyond the uterus: blood tests, liver function tests, a chest x-ray, and computed xtomography (CT) or magnetic resonance imaging (MRI). Other procedures are sometimes required. Staging is based on information obtained from these procedures and during surgery to remove the cancer.

Prognosis and Treatment

kIf endometrial cancer is detected early, nearly 90% of women who have it survive at least 5 years, and most are cured. <The prognosis is better for women whose cancer has not spread beyond the uterus. If the cancer grows relatively slowly, the prognosis is also better. kFewer than one third of women who have this cancer die of it.

Hysterectomy, - the surgical removal of the uterus, is the mainstay of treatment for women who have endometrial cancer. If the cancer has not spread beyond the uterus, removal of the uterus plus removal of the fallopian tubes and ovaries (salpingo(salpingooophorectomy) almost always cures the cancer. Nearby lymph nodes are usually removed at the same time. These tissues are examined by a pathologist to determine whether the cancer has spread and, if so, how far it has spread. With this information, doctors can determine whether additional treatment (chemotherapy, radiation therapy, or a progestin) is needed after surgery.


Chemotherapy - may be given after surgery, even when the cancer does not appear to have spread, in case some undetected cancer cells remain. More than half of women with cancer limited to the uterus do not need radiation therapy. However, if the cancer has spread, radiation therapy is usually needed after surgery.


 

A progestin is often effective. (Progestins are synthetic drugs similar to the hormone progesterone, which blocks the effects of estrogen on the uterus.) If the cancer has spread beyond the uterus, higher doses may be needed. In 15 to 30% of women who have cancer that has spread, a progestin reduces the cancer's size and controls its spread for 2 to 3 years or longer. A progestin may be continued as long as it seems to be working well. Side effects may include mood changes and weight gain due to water retention.

If the cancer has spread, is not responding to a progestin, or recurs, chemotherapy drugs such as cisplatin , cyclophosphamide , doxorubicin and paclitaxel may be used instead of or sometimes with radiation therapy. These drugs are much more toxic than progestins and cause many side effects. However, they reduce the cancer's size and control its spread in more than half of women treated.

II. CERVICAL CANCER The cervix is the lower part of the uterus. It extends into the vagina. Of gynecologic cancers, cervical cancer (cervical carcinoma) is the third most common among all women and the most common among younger women. It usually affects women aged 35 to 55, but it can affect women as young as 20.
This cancer is caused by the human papillomavirus which is transmitted during sexual intercourse. This virus also causes genital warts. The younger a woman was the first time she had sexual intercourse and the more sex partners she has had, the higher her risk of cervical cancer.

About 85% of cervical cancers are squamous cell carcinomas, which develop in the scaly, flat, skinlike cells covering the cervix. Most other cervical cancers are adenocarcinomas, which develop from gland cells, or adenosquamous carcinomas, which develop from a combination of cell types. Cervical cancer begins on the surface of the cervix and can penetrate deep beneath the surface. The cancer can spread directly to nearby tissues, including the vagina. Or it can enter the rich network of small blood and lymphatic vessels inside the cervix, then spread to other parts of the body.

Symptoms and Diagnosis In the early stages, cervical cancer usually causes no symptoms. It may cause spotting or heavier bleeding between periods, bleeding after intercourse, or unusually heavy periods. In later stages, such abnormal bleeding is common. k Other symptoms may include a foulfoulsmelling discharge from the vagina, pain in the pelvic area or lower back, and swelling of the legs. The urinary tract may be blocked; without treatment, kidney failure and death can result.

Routine Papanicolaou (Pap) tests or other similar tests can detect the beginnings of cervical cancer. Cervical cancer begins with slow, progressive changes in normal cells on the surface of the cervix. These changes are called dysplasia. Untreated, these cells may become cancerous with time, sometimes after years. When performing a Pap test, doctors look for these changes as well as for cancer. Women with dysplasia should be checked again in 3 to 4 months.

A Pap test can accurately and inexpensively detect up to 90% of cervical cancers, even before symptoms develop. Consequently, the number of deaths due to cervical cancer has been reduced by more than 50% since Pap tests were introduced. Doctors often recommend that women have their first Pap test when they become sexually active or reach the age of 18 and that a Pap test be performed annually. If test results are normal for 3 consecutive years, women may schedule Pap tests every 2 or 3 years as long as they do not change their sexual lifestyle. Any woman who has had cervical cancer or dysplasia should continue to have Pap tests at least annually. If all women had Pap tests on a regular basis, deaths from this cancer could be virtually eliminated. However, about 50% of American women are not tested regularly.

If a growth, a sore, or another abnormal area is seen on the cervix during a pelvic examination or if a Pap test detects an abnormality or cancer, a biopsy is performed. Usually, doctors use an instrument with a binocular magnifying lens (colposcope) to examine the cervix and to choose the best biopsy site. Two different types of biopsy are performed. In a punch biopsy, a tiny piece of the cervix, selected using the colposcope, is removed.

In endocervical curettage, tissue that cannot be viewed is scraped from inside the cervix. These biopsies cause little pain and a small amount of bleeding. The two together usually provide enough tissue for pathologists to make a diagnosis. If the diagnosis is not clear, doctors perform a cone biopsy to remove a larger cone-shaped piece of tissue. coneUsually, a thin wire loop with an electrical current running through it is used.

This procedure is called the loop electrosurgical excision procedure (LEEP). Alternatively, a laser (using a highly focused beam of light) can be used. Either procedure requires only a local anesthetic and can be performed in the doctor's office. A cold (nonelectric) knife is sometimes used, but this procedure requires an operating room and an anesthetic.

If cervical cancer is diagnosed, its exact size and locations (its stage) are determined. Staging begins with a physical examination of the pelvis and various procedures (such as cystoscopy, a chest x-ray, intravenous urography, xand sigmoidoscopy) to determine whether the cancer has spread to nearby tissues or to distant parts of the body. Other procedures, such as computed tomography (CT), magnetic resonance imaging (MRI), a barium enema, and bone and liver scans, may be performed.

Prognosis and Treatment Prognosis depends on the stage of the cancer. With treatment, 80 to 90% of women with stage I cancer and 50 to 65% of those with stage II cancer are alive 5 years after diagnosis. Only 25 to 35% of women with stage III cancer and 15% or fewer of those with stage IV cancer are alive after 5 years.

 

 

Treatment also depends on the stage. If only the surface of the cervix is involved, doctors can often completely remove the cancer by removing part of the cervix using the loop electrosurgical excision procedure, a laser, or a cold knife. Or cryotherapy may be used to destroy the cancer by freezing it. These treatments preserve a woman's ability to have children.

Because cancer can recur, doctors advise women to return for examinations and Pap tests every 3 months for the first year and every 6 months after that. Rarely, removal of the uterus (hysterectomy) is necessary.

If the cancer has begun to spread within the pelvic area, hysterectomy plus removal of surrounding tissues, ligaments, and lymph nodes (radical hysterectomy) is necessary. The ovaries may be removed. Normal, functioning ovaries in younger women are not removed.

Alternatively, radiation therapy may be used. It usually causes few or no immediate side effects, but it may irritate the bladder or rectum. Later, as a result, the intestine may become blocked, and the bladder and rectum may be damaged. Also, the ovaries usually stop functioning. With either radical hysterectomy or radiation therapy, about 85 to 90% of women are cured.

If the cancer has spread further within the pelvis or to other organs, radiation therapy is preferred. This treatment is ineffective in about 40% of women with large or extensive cancers. When the cancer has spread extensively or recurs, chemotherapy, usually with cisplatin and ifosfamide, is sometimes recommended. However, chemotherapy reduces the cancer's size and controls its spread in only 25 to 30% of women treated, and this effect is usually temporary.

III. FALLOPIAN TUBE CANCER

i The fallopian tubes lead from the ovaries to the uterus. iLess than 1% of gynecologic cancers are fallopian tube cancers. i Most often, cancer that affects the fallopian tubes is cancer that has spread from the ovaries rather than started in the fallopian tubes. i Fallopian tube cancer usually affects women aged 50 to 60. i Occasionally, it appears to be associated with having been infertile.

Symptoms and Diagnosis  Symptoms include vague abdominal discomfort, bloating, and pain in the pelvic area or abdomen. Some women have a watery or bloodbloodtinged discharge from the vagina. Usually, an enlarged mass is found in the pelvis.  The diagnosis is made by viewing the fallopian tubes and surrounding tissues through a thin viewing tube (laparoscope) inserted through a small incision just below the navel or by performing surgery to remove the mass. Biopsies of the surrounding tissues are performed.

Prognosis and Treatment



The prognosis is similar to that for women who have ovarian cancer. Treatment almost always consists of removal of the uterus (hysterectomy) and removal of the ovaries and fallopian tubes (salpingo(salpingo-oophorectomy), adjacent lymph nodes, and surrounding tissues. Chemotherapy (as for ovarian cancer) is usually necessary after surgery. For some cancers, radiation therapy is useful. For cancer that has spread to other parts of the body, removing as much of the cancer as possible improves the prognosis.

IV. HYDATIDIFORM MOLE

- A hydatidiform mole is growth of an abnormal fertilized egg or an overgrowth of tissue from the placenta.

Most often, a hydatidiform mole is an abnormal fertilized egg. The abnormal egg develops into a hydatidiform mole rather than a fetus (a condition called molar pregnancy). However, a hydatidiform mole can develop from cells that remain in the uterus after a miscarriage or a full-term fullpregnancy. Rarely, a hydatidiform mole develops when the fetus is normal.

About 80% of hydatidiform moles are not cancerous and disappear spontaneously. About 15 to 20% invade the surrounding tissue and tend to persist. Of these invasive moles, 2 to 3% become cancerous and spread throughout the body; they are then called choriocarcinomas. Choriocarcinomas can spread quickly through the lymphatic vessels or bloodstream.

The risk of hydatidiform moles is highest for women who become pregnant before age 17 or in their late 30s or later. Hydatidiform moles occur in about 1 of 2,000 pregnancies in the United States and, for unknown reasons, are nearly 10 times more common among Asian women.

Symptoms and Diagnosis  Women who have a hydatidiform mole feel as if they are pregnant. But because hydatidiform moles grow much faster than a fetus, the abdomen becomes larger much faster than it does in a normal pregnancy.


Severe nausea and vomiting are common, and vaginal bleeding may occur. These symptoms indicate the need for prompt evaluation by a doctor. Hydatidiform moles can cause serious complications, including infections, bleeding, and preeclampsia or eclampsia

Often, doctors can diagnose a hydatidiform mole shortly after conception. No fetal movement and no fetal heartbeat are detected. As parts of the mole decay, small amounts of tissue that resemble a bunch of grapes may pass through the vagina. After examining this tissue under a microscope, a pathologist can confirm the diagnosis.

Ultrasonography may be performed to be sure that the growth is a hydatidiform mole and not a fetus or amniotic sac (which contains the fetus and fluid around it). Blood tests to measure the level of human chorionic gonadotropin (HCG (HCGa hormone normally produced early in pregnancy) may be performed. If a hydatidiform mole is present, the level is usually very high because the mole produces a large amount of this hormone.

Treatment  The cure rate for a hydatidiform mole is virtually 100% if the mole has not spread.


The cure rate is 60 to 80% if the hydatidiform mole has spread widely. Most women can have children afterwards and do not have a higher risk of having complications, a miscarriage, or children with birth defects. About 1% of women who have had a hydatidiform mole have another one. So for women who have had a hydatidiform mole, ultrasonography is performed early during subsequent pregnancies.

A hydatidiform mole that does not disappear spontaneously is completely removed usually by dilation and curettage (D and C) with suction Only rarely is removal of the uterus (hysterectomy) necessary

If the hydatidiform mole is detected, a chest x-ray is performed after surgery to xmake sure that it has not become cancerous (that is, a choriocarcinoma) and spread to the lungs. After surgery, the level of human chorionic gonadotropin in the blood is measured to determine whether the hydatidiform mole was completely removed. When removal is complete, the level returns to normal, usually within 8 weeks, and remains normal. Women who have had a mole removed are advised not to become pregnant for 1 year.

Hydatidiform moles do not require chemotherapy, but choriocarcinomas do. Usually, only one drug methotrexate or dactinomycin is needed. Sometimes both or another combination of chemotherapy drugs is needed.

V. OVARIAN CANCER Cancer of the ovaries (ovarian carcinoma) develops most often in women aged 50 to 70. This cancer eventually develops in about 1 of 70 women. It is the second most common gynecologic cancer. However, more women die of ovarian cancer than of any other gynecologic cancer.

The risk of this cancer is higher in industrialized countries because the diet tends to be high in fat. Risk is increased for women who were unable to become pregnant, who had their first child late in life, who started menstruating early, or who reached menopause late. Risk is also increased for women who have a family history of cancer of the uterus, breast, or large intestine (colon). Less than 5% of ovarian cancer cases are related to the BRCA1 gene, which is also related to breast cancer. Use of oral contraceptives significantly decreases risk.

There are many types of ovarian cancer. They develop from the many different types of cells in the ovaries. Cancers that start on the surface of the ovaries (epithelial carcinomas) account for more than 80%. Most other ovarian cancers are germ cell tumors (which start from the cells that produce eggs) and stromal cell tumors (which start in connective tissue). Germ cell tumors are much more common among women younger than 30. Sometimes cancers from other parts of the body spread to the ovaries.

Ovarian cancer can spread directly to the surrounding area and through the lymphatic system to other parts of the pelvis and abdomen. It can also spread through the bloodstream, eventually appearing in distant parts of the body, mainly the liver and lungs.

Symptoms and Diagnosis



Ovarian cancer causes the affected ovary to enlarge. In young women, enlargement of an ovary is likely to be caused by a noncancerous fluid-filled fluidsac (cyst). However, after menopause, an enlarged ovary is often a sign of ovarian cancer.

Many women have no symptoms until the cancer is advanced. The first symptom may be vague discomfort in the lower abdomen, similar to indigestion. Other symptoms may include bloating, loss of appetite (because the stomach is compressed), gas pains, and backache. Ovarian cancer rarely causes vaginal bleeding.

Diagnosing ovarian cancer in its early stages is difficult, because symptoms usually do not appear until the cancer is quite large or has spread beyond the ovaries and because many less serious disorders cause similar symptoms.

Prognosis and Treatment  If ovarian cancer is suspected or confirmed, surgery is performed to remove the mass and to determine how far the cancer has spread (its stage). The prognosis is based on the stage.


With treatment, 70 to 100% of women with stage I cancer and 50 to 70% of those with stage II cancer are alive 5 years after diagnosis. Only 5 to 40% of women with stage III or IV cancer are alive after 5 years.

The extent of surgery depends on the type of ovarian cancer and the stage. If the cancer has not spread beyond the ovary, removal of only the affected ovary and the adjoining fallopian tube may be sufficient. When cancer has spread beyond the ovary, both ovaries and fallopian tubes and the uterus are removed, as are nearby lymph nodes and surrounding structures that the cancer typically spreads through.

If a woman has stage I cancer that affects only one ovary and she wishes to become pregnant, doctors may remove only the affected ovary and fallopian tube. For more advanced cancers that have spread to other parts of the body, removing as much of the cancer as possible improves the prognosis.

VI VAGINAL CANCER Only about 1% of gynecologic cancers occur in the vagina. Cancer of the vagina (vaginal carcinoma) usually affects women older than 45. The average age at diagnosis is 60 to 65.

More than 95% of vaginal cancers are squamous cell carcinomas. Vaginal squamous cell carcinoma may be caused by human papillomavirus (HPV), the same virus that causes genital warts and cervical cancer. Most other vaginal cancers are adenocarcinomas.

One rare type, clear cell carcinoma, occurs almost exclusively in women whose mothers took the drug diethylstilbestrol prescribed to prevent miscarriage during pregnancy. (In 1971, the drug was banned in the United States.)

Depending on the type, vaginal cancer may begin on the surface of the vaginal lining. If untreated, it continues to grow and invades surrounding tissue. Eventually, it may spread to other parts of the body.

Symptoms and Diagnosis



The most common symptom is bleeding from the vagina, which may occur during or after sexual intercourse, between menstrual periods, or after menopause. Sores may form on the lining of the vagina. They may bleed and become infected.

Other symptoms include a watery discharge and pain during sexual intercourse. A few women have no symptoms. Large cancers can also affect the bladder, causing a frequent urge to urinate and pain during urination. In advanced cancer, abnormal connections (fistulas) may form between the vagina and the bladder or rectum.

Doctors may suspect vaginal cancer on the basis of symptoms, abnormal areas seen during a routine pelvic examination, or an abnormal Pap test result. Doctors may use an instrument with a binocular magnifying lens (colposcope) to examine the vagina. To confirm the diagnosis, doctors scrape cells from the vaginal wall to examine under a microscope. They also perform a biopsy on any growth, sore, or other abnormal area seen during the examination.

Prognosis and Treatment



The prognosis depends on the stage of the cancer . If the cancer is limited to the vagina, about 65 to 70% of women survive at least 5 years after diagnosis. If the cancer has spread beyond the pelvis or to the bladder or rectum, only about 15 to 20% survive.

Treatment also depends on the stage. For most vaginal cancers, surgery is the treatment of choice, with or without radiation therapy. Radiation therapy may be internal (using radioactive implants placed inside the vagina) or external (directed at the pelvis from outside the body). Radiation therapy is often combined with or followed by surgical removal of the cancer.

For cancer in the upper third of the vagina, a hysterectomy with removal of lymph nodes in the pelvis and the upper part of the vagina may be needed. For very advanced cancer, surgery is often not possible. In such cases, radiation therapy and chemotherapy are usually used.

Intercourse may be difficult or impossible after treatment for vaginal cancer, although sometimes a new vagina can be constructed with skin grafts or part of the intestine

VII VULVAL CANCER The vulva refers to the area that contains the external female reproductive organs. Cancer of the vulva (vulvar carcinoma) is the fourth most common gynecologic cancer, accounting for only 3 to 4% of these cancers.

Vulvar cancer usually occurs after menopause. The average menopause. age at diagnosis is 70 years. As years. more women live longer, this cancer is likely to become more common. common.

The risk of developing vulvar cancer is increased for women who have persistent itching of the vulva, have genital warts due to human papillomavirus (HPV), or have had cancer of the vagina or cervix.

Most vulvar cancers are skin cancers that develop near or at the opening of the vagina. About 90% of vulvar cancers are squamous cell carcinomas, and 5% are melanomas. The remaining 5% include basal cell carcinomas and rare cancers such as Paget's disease and cancer of Bartholin's gland.

Vulvar cancer begins on the surface of the vulva. Most of these cancers grow slowly, remaining on the surface for years. However, some grow quickly. Untreated, vulvar cancer can eventually invade the vagina, the urethra, or the anus and spread into lymph nodes in the area.

Symptoms and Diagnosis



White, brown, or red patches on the vulva are precancerous; that is, they may indicate that cancer is likely to eventually develop. Vulvar cancer is usually seen and felt as unusual lumps or flat, red sores that do not heal. Sometimes scaly patches develop or the area becomes discolored. The surrounding tissue may contract and pucker.

Usually, vulvar cancer causes little discomfort, but itching is common. Eventually, the lump or sore may bleed or produce a watery discharge (weep). These symptoms should be evaluated promptly by a doctor. About one fifth of women have no symptoms, at least at first.

Doctors diagnose vulvar cancer by performing a biopsy of the abnormal skin. The biopsy can identify whether the abnormal skin is cancerous or just infected or irritated. It also identifies the type of cancer, if present, so that doctors can develop a treatment plan.

Sometimes doctors apply stains to the sores to help determine where to take a sample of tissue for a biopsy. Sometimes an instrument with a binocular magnifying lens (colposcope) is used to examine the surface of the vulva.

Prognosis and Treatment



If vulvar cancer is detected early, about 3 of 4 women have no sign of cancer 5 years after diagnosis. If the lymph nodes are involved, less than one third of women survive for 5 years

Because most vulvar cancers can spread quickly, surgical removal of the vulva (vulvectomy) is usually necessary. Depending on the extent of the cancer, all or part of the vulva is removed. Sometimes nearby lymph nodes are also removed. Treatment with radiation therapy, chemotherapy, or both may be used to shrink very large cancers so that they can be surgically removed. Sometimes the clitoris must be removed.

Doctors work closely with the woman to develop a treatment plan that is best suited to her and takes into account her age, sexual lifestyle, and any other medical problems. Sexual intercourse is usually possible after vulvectomy.

For some small vulvar cancers that do not extend below the skin, treatment consists of removal with a highly focused beam of light (laser surgery), surgical removal of only the skin, or use of an ointment containing a chemotherapy drug (such as fluorouracil )

Because basal cell carcinoma of the vulva does not tend to spread (metastasize) to distant sites, surgery usually involves removing only the cancer. The whole vulva is removed only if the cancer is extensive.

Diagnosis


Regular pelvic examinations and Papanicolaou (Pap) tests can lead to the early detection of certain gynecologic cancers, especially cancer of the cervix and uterus. Such examinations can sometimes prevent cancer by detecting abnormalities (precancerous conditions) before they develop into cancer.

If cancer is suspected, a biopsy can usually confirm or rule out the diagnosis. If cancer is diagnosed, one or more procedures may be performed to determine the stage of the cancer. The stage is based on how large the cancer is and how far it has spread.

Some commonly used procedures include ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), chest x-rays, and bone and liver scans using radioactive substances.

Staging a cancer helps doctors choose the best treatment. Doctors often determine the stage of cancer after they remove the cancer and perform biopsies of the surrounding tissues, including lymph nodes. For cancers of the uterus and ovaries, stages range from I (the earliest) to IV (advanced).

For the other gynecologic cancers, stage 0 is the earliest stage, when the cancer is confined to a surface of the affected organ. For some cancers, further distinctions, designated by letters of the alphabet, are made within stages.

Treatment  The main treatment of gynecologic cancer is surgical removal of the tumor.


Surgery may be followed by radiation therapy or chemotherapy. Radiation therapy may be external (using a large machine) or internal (using radioactive implants placed directly on the cancer). External radiation therapy is usually given several days a week for several weeks. Internal radiation therapy involves staying in the hospital for several days while the implants are in place.

Chemotherapy may be given by injection or by mouth. Chemotherapy is given for 5 days to 6 weeks (depending on the drugs) followed by a recovery period of several weeks without chemotherapy. The cycle may be repeated several times. A woman may have to remain at the hospital while she receives chemotherapy.

When a gynecologic cancer is very advanced and a cure is not possible, radiation therapy or chemotherapy may still be recommended to reduce the size of the cancer or its metastases and to relieve pain and other symptoms. Women with incurable cancer should establish advance directives . Because end-of-life care has improved, end-ofmore and more women with incurable cancer are able to die comfortably at home. Appropriate drugs can be used to relieve the anxiety and pain commonly experienced by people with incurable cancer.