Medical Tribune July 2009 SFIV
David Brill
A novel approach to treating cervical cancer may signal the end of the radical hysterectomy and could one day revolutionize the field of surgical oncology, says a pioneering team of German surgeons.
By removing only the embryologically defined ‘compartments’ in which tumors are most likely to spread, the surgeons can spare surrounding tissues and minimize collateral damage.
The technique reduces complications and recurrence rates, removes the need for radiotherapy, and could improve survival rates by as much as 20 percent compared to conventional hysterectomy, the group reported recently in The Lancet Oncology.
Research is already underway to extend the concept to vulvar and endometrial cancers, said lead researcher Professor Michael Höckel, chairman of the department of obstetrics and gynecology at the University of Leipzig, Germany.
“We have found that the tumor is confined for a long time in its natural course to a defined tissue compartment – it’s not like an explosion infiltrating all tissues around the tumor,” said Höckel.
“This new perspective in surgical anatomy enables you to see and operate on the tissue in which the tumor is spreading, irrespective of the tumor entity. This is a general principle which could really revolutionize surgical treatment for malignant disease,” he said.
The cervical cancer procedure – total mesometrial resection (TMMR) – targets only the non-distal part of the Müllerian compartment. Surgeons remove the proximal vagina, uterus and extra-cervical mesenchyme but spare nearby non-Müllerian tissues, including the nerves which supply the vagina, bladder and rectum.
Results from 212 women who underwent TMMR without radiotherapy at the University of Leipzig show an overall 5-year survival rate of 96 percent, and recurrence-free survival of 94 percent. The study was conducted prospectively from October 1999 to July 2008 on women with early-stage cancers: International Federation of Gynecology and Obstetrics (FIGO) stages IB, IIA and selected IIB. [Lancet Oncol 2009 May 29; Epub ahead of print]
Sixty two percent of procedures were complication-free at a median of 41 months’ follow-up; 35 percent of patients had grade one complications and 9 percent had grade two. Three patients had developed pelvic cancer recurrence, five developed distant recurrences, and two developed both pelvic and distant recurrence.
Höckel and colleagues developed the principle of TMMR by studying uterovaginal development in embryos and fetuses – enabling discrimination of tissue compartments on the basis of their embryological origin. Previous work showed that early cervical tumors grow largely along these lines. [Lancet Oncol 2005 Oct;6(10):751-6]
Singapore surgeon Adjunct Associate Professor Yam Kwai Lam said that he would be “open to any new technique” as long as it provided “substantial overall benefit to the patient.”
“The published results look impressive, but lacking in long-term survival data. In order for the technique to replace conventional hysterectomies, validation would require a large randomized controlled trial to provide the answer,” said Yam, head and senior consultant in the department of gynecological oncology at KK Women’s and Children’s Hospital.
Höckel has previously presented TMMR to surgeons in Southeast Asia – performing live demonstrations in Hong Kong in December 2006, and Bangkok in August 2008.
A multicenter trial is due to launch soon in Germany, with a view to comparing results of 200 TMMRs against 200 conventional hysterectomies. Publication is expected in around 4 years, said Höckel, who has not performed a standard hysterectomy since first developing TMMR some 10 years ago.
“The conventional techniques have no right to exist any longer because they are wrong. Now that we know how a tumor is spreading … it’s no longer acceptable to use these sub-prime concepts and techniques,” he said.
Showing posts with label cervical cancer. Show all posts
Showing posts with label cervical cancer. Show all posts
Thursday, September 3, 2009
Tuesday, September 1, 2009
Age no barrier to continued cervical screening
Medical Tribune June 2009 P9
David Brill
Cervical cancer screening should not stop at age 50, even in women who have had several all-clears in the past, new evidence suggests.
An analysis of national data from the Netherlands found that older women were just as likely to develop cancer after three negative smear tests as younger women.
Previous studies had found that pre-invasive disease is rare in well-screened over-50s, prompting calls for screening to be stopped at this age.
The Dutch study, however, focused instead on the incidence of full-blown cancers. It included data from 445,382 women aged 30 to 44 at the time of their third negative smear, and 218,847 women aged 45 to 54. [BMJ 2009 Apr 24;338:b1354]
After 10 years of follow-up the cumulative incidence of cancer was similarly low: 41 per 100,000 in the younger age group, and 36 per 100,000 in the older age group (P=0.48).
The findings suggest that age should not be the decisive factor for early cessation of screening in well-screened women, said lead author Dr. Matejka Rebolj. They do not, however, provide a definitive answer as to whether it will ultimately prove worthwhile to continue universal screening after three negative tests.
“We cannot really say with these data whether you should continue screening or not. However we can say that if you’re screening younger women, then in order to make your policy consistent you should continue screening women above the age of 50,” said Rebolj, a postdoctoral researcher at the University of Copenhagen, Denmark.
“The next logical step would be to do a proper cost-effectiveness analysis to determine whether this low absolute level of risk does warrant further screening. Until then we should encourage women to continue screening at the regular interval recommended in each particular country.”
Singapore oncologist Dr. Francis Chin praised the quality of the data, and said that the findings support Singapore’s policy of continuing screening up to age 69.
“This study confirms the importance of screening in the age group over 50 years old, because the risk of cervical cancer after several negative smears is similar in older versus younger patients,” said Chin, consultant radiation oncologist at the National Cancer Centre Singapore.
“The predilection of doctors has always been that screening and early detection is better than treating cancer in the later stages. These data confirm and validate this policy,” he said.
Singapore’s Health Promotion Board (HPB) agreed that the study supports the current guidelines of its CervicalScreen Singapore initiative, implemented in 2004. The program, which promotes screening every 3 years, will continue to focus on increasing its coverage of eligible women, said Dr. Shyamala Thilagaratnam, director, Healthy Ageing Division, HPB.
Several previous studies have proposed that cervical screening should stop at 50, notably a 1997 paper which found that only 1 percent of 23,440 previously screened over-50s had significant cytological abnormalities. The authors concluded that ending screening in this group could reduce anxiety and enable better allocation of resources to targeting higher-risk women. [Br J Obstet Gynaecol 1997 May;104(5):586-9]
The case against this argument, however, could be furthered strengthened by another recent paper, supporting the findings of the Dutch study. UK researchers, reviewing National Health Service screening records for 2 million women, found that two thirds of all the lesions detected in over-50s were found in women who had had previously had negative smears results. Discontinuation of screening would therefore lead to the majority of important abnormalities being missed, the researchers say. [Br J Cancer 2009 May 5; Epub ahead of print]
Singapore physician Dr. Siew Wei Fong concurred with the conclusion that screening should continue beyond the age of 50, in light of the recent evidence. She added that she does not expect any change in screening practices at the Singapore Polyclinics, where she is senior family physician.
Previous studies had found that pre-invasive disease is rare in well-screened over-50s, prompting calls for screening to be stopped at this age.
The Dutch study, however, focused instead on the incidence of full-blown cancers. It included data from 445,382 women aged 30 to 44 at the time of their third negative smear, and 218,847 women aged 45 to 54. [BMJ 2009 Apr 24;338:b1354]
After 10 years of follow-up the cumulative incidence of cancer was similarly low: 41 per 100,000 in the younger age group, and 36 per 100,000 in the older age group (P=0.48).
The findings suggest that age should not be the decisive factor for early cessation of screening in well-screened women, said lead author Dr. Matejka Rebolj. They do not, however, provide a definitive answer as to whether it will ultimately prove worthwhile to continue universal screening after three negative tests.
“We cannot really say with these data whether you should continue screening or not. However we can say that if you’re screening younger women, then in order to make your policy consistent you should continue screening women above the age of 50,” said Rebolj, a postdoctoral researcher at the University of Copenhagen, Denmark.
“The next logical step would be to do a proper cost-effectiveness analysis to determine whether this low absolute level of risk does warrant further screening. Until then we should encourage women to continue screening at the regular interval recommended in each particular country.”
Singapore oncologist Dr. Francis Chin praised the quality of the data, and said that the findings support Singapore’s policy of continuing screening up to age 69.
“This study confirms the importance of screening in the age group over 50 years old, because the risk of cervical cancer after several negative smears is similar in older versus younger patients,” said Chin, consultant radiation oncologist at the National Cancer Centre Singapore.
“The predilection of doctors has always been that screening and early detection is better than treating cancer in the later stages. These data confirm and validate this policy,” he said.
Singapore’s Health Promotion Board (HPB) agreed that the study supports the current guidelines of its CervicalScreen Singapore initiative, implemented in 2004. The program, which promotes screening every 3 years, will continue to focus on increasing its coverage of eligible women, said Dr. Shyamala Thilagaratnam, director, Healthy Ageing Division, HPB.
Several previous studies have proposed that cervical screening should stop at 50, notably a 1997 paper which found that only 1 percent of 23,440 previously screened over-50s had significant cytological abnormalities. The authors concluded that ending screening in this group could reduce anxiety and enable better allocation of resources to targeting higher-risk women. [Br J Obstet Gynaecol 1997 May;104(5):586-9]
The case against this argument, however, could be furthered strengthened by another recent paper, supporting the findings of the Dutch study. UK researchers, reviewing National Health Service screening records for 2 million women, found that two thirds of all the lesions detected in over-50s were found in women who had had previously had negative smears results. Discontinuation of screening would therefore lead to the majority of important abnormalities being missed, the researchers say. [Br J Cancer 2009 May 5; Epub ahead of print]
Singapore physician Dr. Siew Wei Fong concurred with the conclusion that screening should continue beyond the age of 50, in light of the recent evidence. She added that she does not expect any change in screening practices at the Singapore Polyclinics, where she is senior family physician.
Monday, May 25, 2009
Vaccinate the young against HPV, says Nobel Laureate
Medical Tribune May 2009 SFIII
David Brill
Countries should “seriously consider” offering widespread human papillomavirus (HPV) vaccinations, according to the Nobel Prize-winning scientist who first linked the virus to cervical cancer.
Professor Harald zur Hausen, addressing the media on a recent visit to Singapore, said that boys and girls alike would benefit from the vaccine, but stressed that it should be given prior to the onset of sexual activity.
For older women who are already sexually active, it should be a personal decision whether or not to be vaccinated, he said.
zur Hausen also rejected the argument that effective screening programs can be superior to widespread vaccination.
“I think that’s a mistake because screening and vaccination do something different,” he said. “In screening you discover lesions which need to be removed. In vaccination you prevent the lesions, and therefore you don’t [need] surgical intervention.”
Vaccination has been shown to be safe and highly effective for preventing HPV infections but opinions remain divided about who, when and how to vaccinate. Australia, for example, has approved vaccination of women aged 10 to 45, whereas the US FDA limits approval to 9 to 26 year-olds.
“It would really be something which one should seriously consider – to vaccinate everyone,” said zur Hausen, winner of the 2008 Nobel Prize in Physiology or Medicine.
“[But] let me be quite clear about it – the vaccine is really only protective in preventing the infection. If there has [already] been an infection the vaccine has no effect whatsoever.
“Up to the onset of sexual activity, yes, you can clearly say it’s worthwhile. But subsequently it’s more difficult to make a statement along those lines.”
Neither of the HPV vaccines is presently approved for use in males, but zur Hausen outlined several supporting arguments. Firstly, it would protect women from cervical cancer by reducing HPV transmission. Secondly, men themselves would gain protection from genital warts and other HPV-positive cancers, including anal and oropharyngeal cancers. Upcoming data from the first clinical studies in boys “look very promising,” he said.
zur Hausen also called for reductions in the price of HPV vaccines, which are presently “unaffordable” for parts of the developing world. This would pave the way for global vaccination programs, offering “the theoretical chance to eradicate some of these infections which lead to cervical cancer.”
Professor zur Hausen delivered the 6th Humphrey Oei Distinguished Lecture at the National Cancer Center, Singapore, and the second opening lecture at the Asian Oncology Summit 2009.
For older women who are already sexually active, it should be a personal decision whether or not to be vaccinated, he said.
zur Hausen also rejected the argument that effective screening programs can be superior to widespread vaccination.
“I think that’s a mistake because screening and vaccination do something different,” he said. “In screening you discover lesions which need to be removed. In vaccination you prevent the lesions, and therefore you don’t [need] surgical intervention.”
Vaccination has been shown to be safe and highly effective for preventing HPV infections but opinions remain divided about who, when and how to vaccinate. Australia, for example, has approved vaccination of women aged 10 to 45, whereas the US FDA limits approval to 9 to 26 year-olds.
“It would really be something which one should seriously consider – to vaccinate everyone,” said zur Hausen, winner of the 2008 Nobel Prize in Physiology or Medicine.
“[But] let me be quite clear about it – the vaccine is really only protective in preventing the infection. If there has [already] been an infection the vaccine has no effect whatsoever.
“Up to the onset of sexual activity, yes, you can clearly say it’s worthwhile. But subsequently it’s more difficult to make a statement along those lines.”
Neither of the HPV vaccines is presently approved for use in males, but zur Hausen outlined several supporting arguments. Firstly, it would protect women from cervical cancer by reducing HPV transmission. Secondly, men themselves would gain protection from genital warts and other HPV-positive cancers, including anal and oropharyngeal cancers. Upcoming data from the first clinical studies in boys “look very promising,” he said.
zur Hausen also called for reductions in the price of HPV vaccines, which are presently “unaffordable” for parts of the developing world. This would pave the way for global vaccination programs, offering “the theoretical chance to eradicate some of these infections which lead to cervical cancer.”
Professor zur Hausen delivered the 6th Humphrey Oei Distinguished Lecture at the National Cancer Center, Singapore, and the second opening lecture at the Asian Oncology Summit 2009.
Singapore to wait and see on HPV vaccination
Medical Tribune May 2009 SFIII
David Brill
Singapore will not rush to make human papillomavirus (HPV) vaccination part of its national immunization program.
Insteady, the city-state will await the outcomes of vaccination programs in other countries before making its own decision, said Dr. Balaji Sadasivan, senior minister of state, Ministry of Foreign Affairs.
In the meantime, the nation will continue strengthening its Pap smear screening coverage. The HPV vaccine will remain available on an optional basis, giving individual parents the right to choose whether to vaccinate their daughters.
“As a country with a lower incidence of cervical cancer, the risk-benefit ratio will be lower in Singapore. We should therefore be cautious in making any national recommendation with regard to vaccination,” said Balaji at the recent Asian Oncology Summit 2009.
“If we put it in our national immunization program almost every young girl will get vaccinated. That’s a very, very major step, and sometimes … it’s not necessarily the wisest thing to be the first to try something out because you’re basically the guinea pig. It may just be safer to wait and see how other countries proceed with this.”
Balaji singled out the UK in particular as one “for us to watch,” following the September 2008 introduction of a national HPV immunization program for girls aged 12 to 13. “If it turns out to be safe to do it on a national scale then I think it would make sense for us to consider doing the same thing,” he said, adding that it would be “a few years” before any conclusions could be made.
Balaji also expressed clinical concerns about the vaccine, notably that it remains unclear whether immunity is long-lasting. It is also unknown whether other strains of HPV could become dominant if current strains are contained.
“From an ethical standpoint, there is also the issue of consent, which has to be viewed in the local context, where the community’s moral viewpoint is that offering such a vaccination program sends out the wrong message – that teenage sex is condoned by the community,” he said.
“Pap smear screening is one of the most effective ways of reducing the risk of cervical cancer, and we have pretty good coverage of about 60 to 70 percent. We should continue to build on that program and not neglect [it] because of the possibility of vaccination. That is a reasonable alternative while waiting to have better data,” he concluded.
Dr. Balaji delivered the opening address at the Asian Oncology Summit 2009, and spoke directly with the media.
David Brill
Singapore will not rush to make human papillomavirus (HPV) vaccination part of its national immunization program.
Insteady, the city-state will await the outcomes of vaccination programs in other countries before making its own decision, said Dr. Balaji Sadasivan, senior minister of state, Ministry of Foreign Affairs.
In the meantime, the nation will continue strengthening its Pap smear screening coverage. The HPV vaccine will remain available on an optional basis, giving individual parents the right to choose whether to vaccinate their daughters.
“As a country with a lower incidence of cervical cancer, the risk-benefit ratio will be lower in Singapore. We should therefore be cautious in making any national recommendation with regard to vaccination,” said Balaji at the recent Asian Oncology Summit 2009.
“If we put it in our national immunization program almost every young girl will get vaccinated. That’s a very, very major step, and sometimes … it’s not necessarily the wisest thing to be the first to try something out because you’re basically the guinea pig. It may just be safer to wait and see how other countries proceed with this.”
Balaji singled out the UK in particular as one “for us to watch,” following the September 2008 introduction of a national HPV immunization program for girls aged 12 to 13. “If it turns out to be safe to do it on a national scale then I think it would make sense for us to consider doing the same thing,” he said, adding that it would be “a few years” before any conclusions could be made.
Balaji also expressed clinical concerns about the vaccine, notably that it remains unclear whether immunity is long-lasting. It is also unknown whether other strains of HPV could become dominant if current strains are contained.
“From an ethical standpoint, there is also the issue of consent, which has to be viewed in the local context, where the community’s moral viewpoint is that offering such a vaccination program sends out the wrong message – that teenage sex is condoned by the community,” he said.
“Pap smear screening is one of the most effective ways of reducing the risk of cervical cancer, and we have pretty good coverage of about 60 to 70 percent. We should continue to build on that program and not neglect [it] because of the possibility of vaccination. That is a reasonable alternative while waiting to have better data,” he concluded.
Dr. Balaji delivered the opening address at the Asian Oncology Summit 2009, and spoke directly with the media.
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