Spotlight on…gynaecological cancer

Much has changed in the emphasis of gynaecological cancer in the working practices of the generalist in obstetrics and gynaecology. When I was a trainee and in my early years as a consultant there was no such thing as a fast-track clinic. This meant that there was a chance of encountering a cancer at any gynaecology clinic so a high index of suspicion was required. A consequence of the new referral system is that generalist gynaecologists and their trainees don't expect to see new patients with cancer and the subsequent surgical treatment is performed by gynaecological oncologists or local lead consultants. The reality is that generalists will still unexpectedly encounter gynaecological malignancies either in the clinic or the operating theatre and therefore TOG needs to cover oncological topics appropriately. Another consequence of the subspecialisation is that issues that trouble gynaecological oncologists may not be generally understood. TOG has published a range of reviews and discussions on gynaecological oncology. I have chosen a selection to represent some of the issues. They also illustrate the need to regularly revisit topics with time as even some recent authoritative reviews have rapidly become out of date. In 2003 Lawton (TOG 2003;5:79–83) gave a very good description of the prognostic issues which holds true today. Although written only 11 years ago, the laparoscopic approach merits only two sentences! He introduces the debate regarding lymphadenectomy and the proposed ASTEC trial (ASTEC study group. Lancet 2009 373:125–36). However, ASTEC polarised views still further and TOG published two articles on this subject from either side of the Atlantic. Holland (TOG 2009;11:205–9) and Mariani et al. (TOG 2009:11;199–204) voice the differing views which persist over the role of lymph node surgery in endometrial cancer. Surgery has developed considerably in the past decade due in part to new trial evidence. Sean Kehoe (TOG 2000;2:5–8) wrote a balanced paper in 2000. ‘Debulking’ was still the aim of surgery and delayed primary surgery and supra-radical surgery were still in the future. Nagar and Dobbs (TOG 2007;9:243–7) have described the difficulties in early ovarian cancer that a generalist gynaecologist can still encounter unexpectedly. Another rare clinical scenario encountered by the generalist is a germ cell tumour. Found predominantly in young women, possible malignancy is often not considered. Sanusi et al. (TOG 2000;2:37–9) cover this situation. Despite the public perception, it is uncommon in Britain. Worldwide, the situation is very different. How to cope with cervical cancer in a developing country is the topic described by McGregor and Olaitan (TOG 2010;12:49–52). Unlike cervical cancer is slowly increasing in incidence. As not always suspected by the GP, patients may turn up in any clinic. Bailey and Luesley (TOG 2013;15:227–31) recently gave a useful update on the diagnosis and management of vulval cancer. Borderline ovarian tumours and uterine sarcoma have been discussed (TOG 2012;14:115–20; TOG 2007;9:88–94). These perhaps are the two tumours likely to be seen by generalists mistaken for benign cysts and fibroids. Rare but often not recognised, vulval intraepithelial neoplasia has recently been covered (TOG 2011;13:73–8). Finally the topic of treatment-related complications which affect many women has been reviewed (TOG 2010;12: 79–86). Cancer accounts for a high proportion of gynaecological complaints to Trusts and the Ombudsman and, though uncommon for the individual generalist, remains an important part of our speciality. I hope this has shown why it is vital that TOG continues to publish reviews on gynaecological oncology. The editorial board is always keen to receive suggestions or submitted abstracts, especially if a topic is identified that needs revisiting or has not been covered previously. A virtual online issue of all TOG articles on gynaecological cancer is available at http://onlinetog.org.