Cancer is the second leading cause of death after cardiovascular diseases with a rate of 22% in the world and Turkey. According to the 2009 statistics of the Ministry of Health, breast cancer is one of the most common female cancers in Turkey.

Any cancer that starts in the female reproductive organs is defined as gynecological cancer. Cancer of the endometrium, ovary, and cervix that occurs in women is also among the top 10 most common cancers.

Screening methods for gynecological cancers are extremely important. With regular health checks, it is possible to catch cancer at an early stage and even at the stage of precursor lesions and to take precautions.

Are All Women at Risk for Gynecological Cancers?

It is not possible to generalize this question to all gynecological cancers. Each of them has different behavior and risk of incidence. For example, cervical cancer is most often a disease of women over the age of 30. It continues to emerge without increasing after the age of 45-50. Its emergence is extremely rare over the age of 65.

What are the Risk Factors in Cervical Cancer?

• HPV Is Effective in Cervical Cancer

HPV (Human papilloma virus) is active in nearly 100 percent (99.7%) of cervical cancers. In addition, in many studies, cervical intraepithelial neoplasia (pre-cancerous lesion CIN II-III) or cervical cancer has been reported extremely rarely in HPV-negative women. Therefore, the most important factor that increases the risk is sexual intercourse with partners who are at risk of transmitting HPV. Especially in polygamous people, the transmissibility of HPV is at an increased rate. Other accompanying factors increase the risk of cervical cancer.

• Smoking Increases Cancer Risk by Lowering Immunity

Additional risk factors are that infections such as HIV (AIDS), which causes weakening of the immune system, become effective in the development of cancer, that they are encountered due to decreased immunity in smokers, and that they are observed together with vaginal infections such as sexually transmitted chlamydia, herpes, and gonorrhea. Studies have shown that the risk of developing cancer increases 5 times with the use of oral contraceptives and maintaining the habit of smoking.

• Family History is Important in Ovarian Cancer

The most important and consistent risk factor for ovarian cancer is heredity and especially 1st-degree proximity. There is a 3.6 times increased risk of ovarian cancer in first-degree relatives and 2.9 times increased risk in second-degree relatives. About 10-12 percent of women with ovarian cancer are carriers of the BRCA 1 and 2 mutations. Also, 2-3 percent have hereditary nonpolyposis coli (HNPCC) or Lynch syndrome. Again, in such inherited syndromes, bowel, ovarian, endometrial, breast and stomach cancers can occur throughout life. The most important feature of hereditary cancers is that they occur at an early age and that breast and ovarian cancer can be seen together. At the forefront of the precautions to be taken in this case, genetic counseling should be given to women at risk and genetic tests such as BRCA 1,2 should be performed. 

Hormonal risk factors encountered in reproductive age may cause a predisposition to ovarian cancer. For example, while this risk increases in infertile patients, no evidence has been found that the controversial medications used for infertility or ovulation in IVF treatments are risk factors. In addition, it is seen that the risk of ovarian cancer decreases in those who use birth control pills for a long time and those who have given multiple births. There may be an increased risk of breast and ovarian cancer in people who menstruate at an early age (before 12 years of age) and go through menopause at a late age (after 52 years of age). 

• Endometriosis Patients Need Regular Follow-up

Although rare, coexistence with some types of ovarian cancer for which the relationship between endometriosis and ovarian cancer has been investigated, requires close evaluation of ultrasonographic follow-ups and necessary tumor markers, taking into account the risk in this regard.

Protective factors for ovarian cancer: It is possible to count factors such as the use of oral contraceptives, increasing the number of births, having the tubes removed or tied, and keeping the breastfeeding period long.

What Does Screening for Gynecological Cancers Mean?

Screening tests are tests performed at regular intervals to detect cancer. The vaginal smear test, which is defined as the PAP test performed for cervical cancer, and HPV - DNA test, which is done by examining the secretion taken from the vagina, are the most important screening tests. By examining them together at the same time, the chance of catching cancer, that is, the sensitivity of the screening, increases even more. Although there is no special screening test for catching other gynecological cancers, it is possible to evaluate the ovaries in the abdomen with ultrasound during annual controls and to look for tumor markers in the blood in case of abnormal growth or suspicious cysts. Likewise, for endometrial cancers, it is possible to perform a follow-up in case of an increase in the intrauterine tissue thickness (endometrial line) above the normal value with ultrasound or perform follow-up, which can be stated as a biopsy, instead of screening.

It has been observed that the incidence of cervical cancer has decreased significantly in countries where the screening program for cervical cancer is fully implemented. While its incidence is 10/100.000 in countries that implement the national screening program, it is 50/100.000 in countries that do not.

Since 1949, when Pap smear screening was started, a 75 percent reduction in cancer incidence and a 74 percent reduction in mortality have been achieved. It has been ensured that vaginal smear screening is performed every three years starting from the age of 21 at the earliest when sexual life starts or starting from the age of 25 in adults, and if HPV and vaginal smear screening are performed together from the age of 30 and above (co-test), the screening is performed every 5 years instead of every 3 years.

What is the Importance of Screening for Gynecological Cancers?

There are more than 200 types of HPV available today. While low-risk types cause genital warts, types 16 and 18, which are defined as the most common high-risk types, and other moderately high-risk types (31, 33, 35, 39, 51, 52, 56, 58, 66) cause cancer. However, in most of the women exposed to this type of infection before the age of 30, it is possible to clear the HPV infection within 1 year. However, those whose infection is not cleared and persists are examined by vaginal smear and HPV typing follow-ups, colposcopic examination, and biopsies (cervical intraepithelial neoplasia CIN I, II, III), and if necessary, it is possible to prevent the development and progression of cancer by removing the part of the lesion in the cervix defined as conization. 

For Which Gynecological Cancers Is Vaccine Effective?

While studies on the applicability of therapeutic vaccines continue, preventive vaccines are widely used all over the world, and even in some countries, it is seen that they are among the vaccine application protocols of the state. In addition to double vaccines effective only against types 16 and 18, quadruple vaccines effective against 6, 11, 16, and 18 viruses, which protect warts, are also used in our country. The 9-way vaccines, which are not yet available in our country, have been started to be administered to men as well. Vaccination applications are recommended as 2 doses (with an interval of 6 months) in the 9-11 years of age, years before the start of sexual life, and as 3 doses (in the 2nd and 6th months) in the 12-26 years of age and over. Because, within 5-10 years after vaccination, antibody levels can increase, that is, protection is provided. However, even if they have been vaccinated, it is extremely important that these individuals continue their routine screening program and not abandon them because of the possibility of encountering other types of the virus.