Gynecologic oncology

Gynecologic Oncologist
Occupation
Names
  • Physician
  • Surgeon
Occupation type
Specialty
Activity sectors
Medicine, Surgery
Description
Education required
Fields of
employment
Hospitals, Clinics

Gynecologic oncology is a specialized field of medicine that focuses on cancers of the female reproductive system, including ovarian cancer, uterine cancer, vaginal cancer, cervical cancer, and vulvar cancer. As specialists, they have extensive training in the diagnosis and treatment of these cancers.

In the United States, 82,000 women are diagnosed with gynecologic cancer annually.[1] In 2013, an estimated 91,730 were diagnosed.[2]

The Society of Gynecologic Oncology and the European Society of Gynaecological Oncology are professional organizations for gynecologic oncologists, and the Gynecologic Oncology Group is a professional organization for gynecological oncologists as well as other medical professionals who deal with gynecologic cancers. The Foundation for Women's Cancer is the major U.S. organization that raises awareness and research funding and provides educational programs and materials about gynecologic cancers.

There is low quality evidence which demonstrates women with gynaecological cancer receiving treatment from specialized centres benefit from longer survival than those managed in standard care.[3] A meta analysis of three studies combining over 9000 women, suggested that specialist gynaecological cancer treatment centres may prolong the lives of women with ovarian cancer compared with general or community hospitals. In addition, a meta‐analysis of three other studies which assessed over 50,000 women, found that teaching centres or specialized cancer centres may prolong women’s lives compared to those treated in community or general hospitals.

Gynecological cancers comprise 10-15% of women’s cancers, mainly affecting women past reproductive age but posing threats to fertility for younger patients.[4] The most common route for treatment is combination therapy, consisting of a mix of both surgical and non-surgical interventions (radiotherapy, chemotherapy).[4]

Risk factors

Obesity

Obesity is associated with an increased risk of developing gynecologic cancers such as endometrial and ovarian cancer.[5] For endometrial cancer, every 5-unit increase on the BMI scale was associated with a 50-60% increase in risk.[6] Type 1 endometrial cancer is the most common endometrial cancer.[7] As many as 90% of patients diagnosed with Type 1 endometrial cancer are obese.[8] Although a correlation between obesity and ovarian cancer is possible, the association is predominantly found in low-grade subtypes of the cancer.[9]

Genetic mutations

Genetic mutations such as the BRCA1 and BRCA2 have been strongly linked to the development of ovarian cancer.[10] The BRCA1 mutation has been shown to increase the risk of developing ovarian cancer by 36% - 60%.[11] The BRCA2 mutation has been shown to increase the risk of developing ovarian cancer by 16% - 27%.[11]

Human Papilloma Virus (HPV)

Human Papilloma Virus (HPV) is a common sexually transmitted disease that has been associated with some gynecologic cancers, including those of the cervix, vagina, and vulva.[12] A clear link between human papilloma virus and cervical cancer has long been established, with HPV associated with 70% to 90% of cases.[13] Persistent human papilloma virus infections have been shown to be a driving factor for 70% to 75% of vaginal and vulvar cancers.[13]

Smoking

Smoking has been found to be a risk factor for the development of cervical, vulvar and vaginal cancer.[14][15][16] Current women smokers are twice as likely to develop cervical cancer compared to their non-smokers counterparts.[14] Several mechanisms have been researched to understand how smoking plays a role in the development of cervical cancer.[17] The cervical epithelium's DNA has been shown to be damaged due to smoking.[17] DNA damage levels in the cervix cells were higher in smokers when compared to non-smokers.[17] It has also been postulated that smoking can lower the immune response to HPV as well as amplify the HPV-infection in the cervix.[18] Through similar mechanisms, women smokers have also been found to be 3 times more likely to develop vulvar cancer.[19][20] Smoking has also been associated with an elevated risk for vaginal cancer.[21][16] Woman smokers are at double the risk for developing vaginal cancer when compared to women non-smokers.[21][16]

Infertility

Infertility is a common disease affecting young adults.[22] Some studies have shown that 1 in every 7 couples will fail to conceive due to infertility problems.[22] Infertility is a known risk factor for gynecologic cancers.[23] Infertile women are at a higher risk of developing ovarian cancer and endometrial cancer when compared to fertile women.[23]

Signs and symptoms

Signs and symptoms usually vary depending on the type of cancer. The most common symptoms across all gynecological cancers are abnormal vaginal bleeding, vaginal discharge, pelvic pain and urination difficulties.[24]

Ovarian cancer[24][25]

  • Bloating or abdominal swelling
  • Frequent urination
  • Pelvic or back pain
  • Increased satiety/loss of appetite
  • Altered bowel movements
  • Fatigue
  • Weight loss

Endometrial cancer[24][26][27]

  • Post-menopausal bleeding
  • Abnormal vaginal bleeding (heavy or irregular menstrual cycles)
  • Vaginal discharge
  • Difficulty urinating
  • Pelvic pain

Vaginal cancer[28][29]

  • Abnormal vaginal bleeding
  • Vaginal discharge
  • Pelvic Pain
  • Painful and frequent urination

Cervical cancer[24][30]

  • Abdominal pain
  • Foul-smelling vaginal discharge
  • Pelvic pain and/or back pain
  • Blood spotting
  • Post-menopausal bleeding

Vulvar cancer[31][32]

  • Pruritus: persistent itch in the vulva
  • Vulvar bleeding
  • Vulvar pain, soreness or tenderness
  • Burning sensation when urinating
  • A visible wart-like mass or sore on the vulva

Treatments

Ovarian cancer

The vast majority of cases are detected past point of metastasis beyond ovaries, implicating higher risk of morbidity and a need for aggressive combination therapy. Surgery and cytotoxic agents are typically required.[4][33] Histology type is almost primarily epithelial, so treatments will refer to this subtype of pathology.[4][33]

Ovarian cancer is highly treatable with surgery for almost all cases with well-differentiated stage-1 tumour.[4][34] Higher tumour grades may benefit from adjuvant treatment such as platinum-based chemotherapy.[4][34]

Optimal debulking is used to treat cases where cancer has spread to become macroscopically advanced.[4][35] The goal of this procedure is to leave no tumour larger than 1 cm by the removal of significant portions of affected reproductive organs.[4][35] Multiple interventions may be used to achieve optimal debulking, including abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, lymph node sampling, and peritoneal biopsies.[4][35] There is a lack of randomized controlled trials comparing outcomes between chemotherapy and optimal debulking, so the current standard of care typically involves the sequential administration of both, beginning with surgical interventions.[4]

Interval debulking surgery may be employed half way through chemotherapy following primary surgery if tumour remains above 1 cm in diameter.[4][36] This has been shown to increase median survival of chemosensitive patients by up to 6 months.[4][36]

A second look laparotomy may be used to assess tumour status in clinical trials, but is not a staple of standard care due to a lack of association with improved outcomes.[4][37]

Fertility preserving surgery involves a thorough differential diagnosis to rule out germ cell cancer or abdominal lymphoma, both of which resemble advanced ovarian cancer in presentation but are treatable with gentler methods.[4][38] Fertility preserving surgery is one of the few cases where a second look laparotomy is recommended for caution.[4][38]

Platinum-based chemotherapy is paramount to treatment of epithelial ovarian cancer. Carboplatin tends to fare better than cisplatin for side effects and use in outpatient setting in randomized clinical trials.[4] Paclitaxel is a particularly effective add-on for late stage ovarian cancer.[4] Some studies suggest that intraperitoneal chemotherapy may be advantageous over an intravenous route.[4]

Cervical cancer

Cervical cancer is treated with surgery up to stage 2A.[4][39] Local excision via loop cone biopsy is sufficient if detected in the earliest stage.[4][39] If a patient presents beyond this point, bilateral lymphadenectomy is performed to assess metastasis to pelvic lymph nodes.[4] If lymph nodes are negative, then excision of the uterus is performed.[4] Otherwise, a combination of hysterectomy and radiotherapy is frequently employed.[4] This combination approach may be substituted with chemoradiotherapy alone in some.[4]

Endometrial cancer

Hysterectomy and bilateral oophorectomy is performed for early stage disease.[4][40] More aggressive cases with lymphatic spread are often treated with radiotherapy.[41] Hormone therapy is most commonly used to treat systemic spread, as endometrial cancer patients tend to be older and suffer from other illnesses that make them poor candidates to withstand harsh cytotoxic agents used in chemotherapy.[4][41] Minimal laparoscopic surgery is used for endometrial cancer more than any other gynecologic cancer, and may confer advantages over classical surgical interventions.[4]

Vulvar cancer

Low incidence means that evidence-based therapy is relatively weak, but emphasis is placed on accurate assessment of cancerous tissue and reducing lymphatic spread.[42]

The minority of non-squamous histological subtypes do not typically require removal of the inguinal nodes.[4][42] However, this is necessary to prevent spread in squamous cell carcinomas exceeding 1 mm in stromal invasion.[4][42] If nodal disease is confirmed, adjuvant radiotherapy is administered.[4][42]

Vaginal cancer

Treatment depends on the stage of vaginal cancer.[43] Surgical resection and definitive radiotherapy are the first-line of treatment for early-stage vaginal cancer.[43] Surgery is preferred over radiotherapy due to the preservation of the ovaries and sexual function as well as the elimination of the risk of radiation.[43] For more advanced stages of vaginal cancer, external-beam radiation therapy (EBRT) is the standard method for treatment.[43] External-beam radiation therapy involves the delivery of a boost to the pelvic side of the patient at a 45 Gy dose.[43]

Epidemiology

  • 1 in 70 women will develop ovarian cancer at some point in their life. Scandinavian countries have an incidence appropriately 6.5 times higher than that of Japan’s. This is due to multifactorial reasons, both of genetic and environmental nature.[4]
  • Cervical cancer makes up the largest percentage of gynaecological cancers.[4] Women in developing countries tend to present with more advanced cases.[4]

Quality of life

Sexuality

The experience of cancer influences the psychological aspect of sexuality, by posing a risk of developing barriers such as body image issues, low self esteem, and low mood or anxiety.[44] Other barriers include changes to reproductive organs or sex drive as well as potential genital pain.[44] Partners may also be affected by these changes in the relationship, especially with regards to intimacy and sexuality, which may in turn affect gynecological cancer patients by creating a perception of adverse relationship outcomes such as emotional distance or lack of interest.[45][44]

See also

References

  1. ↑ "Gynecologic Cancer". Mount Sinai Hospital.
  2. ↑ "About Gynecologic Cancers". Foundation for Women's Cancer. Archived from the original on 2016-08-13. Retrieved 2014-07-21.
  3. ↑ Woo YL, Kyrgiou M, Bryant A, Everett T, Dickinson HO (March 2012). "Centralisation of services for gynaecological cancer". The Cochrane Database of Systematic Reviews (3): CD007945. doi:10.1002/14651858.cd007945.pub2. PMC 4020155. PMID 22419327.
  4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 Kehoe, Sean (2006-12-01). "Treatments for gynaecological cancers". Best Practice & Research Clinical Obstetrics & Gynaecology. Evidence-Based Gynaecology: Part II. 20 (6): 985–1000. doi:10.1016/j.bpobgyn.2006.06.006. ISSN 1521-6934. PMID 16895764.
  5. ↑ McTiernan, Anne; Irwin, Melinda; VonGruenigen, Vivian (2010-09-10). "Weight, Physical Activity, Diet, and Prognosis in Breast and Gynecologic Cancers". Journal of Clinical Oncology. 28 (26): 4074–4080. doi:10.1200/JCO.2010.27.9752. ISSN 0732-183X. PMC 2940425. PMID 20644095.
  6. ↑ Webb, Penelope M. (2013-05-16). "Obesity and Gynecologic Cancer Etiology and Survival". American Society of Clinical Oncology Educational Book (33): e222–e228. doi:10.14694/EdBook_AM.2013.33.e222. ISSN 1548-8748. PMID 23714508.
  7. ↑ Setiawan, Veronica Wendy; Yang, Hannah P.; Pike, Malcolm C.; McCann, Susan E.; Yu, Herbert; Xiang, Yong-Bing; Wolk, Alicja; Wentzensen, Nicolas; Weiss, Noel S.; Webb, Penelope M.; van den Brandt, Piet A. (2013-07-10). "Type I and II Endometrial Cancers: Have They Different Risk Factors?". Journal of Clinical Oncology. 31 (20): 2607–2618. doi:10.1200/JCO.2012.48.2596. ISSN 0732-183X. PMC 3699726. PMID 23733771.
  8. ↑ Olsen, Catherine M.; Green, Adèle C.; Whiteman, David C.; Sadeghi, Shahram; Kolahdooz, Fariba; Webb, Penelope M. (2007-03-01). "Obesity and the risk of epithelial ovarian cancer: A systematic review and meta-analysis". European Journal of Cancer. 43 (4): 690–709. doi:10.1016/j.ejca.2006.11.010. ISSN 0959-8049. PMID 17223544.
  9. ↑ Olsen, Catherine M.; Nagle, Christina M.; Whiteman, David C.; Ness, Roberta; Pearce, Celeste Leigh; Pike, Malcolm C.; Rossing, Mary Anne; Terry, Kathryn L.; Wu, Anna H.; Risch, Harvey A.; Yu, Herbert (2013-04-01). "Obesity and risk of ovarian cancer subtypes: evidence from the Ovarian Cancer Association Consortium". Endocrine-Related Cancer. 20 (2): 251–262. doi:10.1530/ERC-12-0395. ISSN 1351-0088. PMC 3857135. PMID 23404857.
  10. ↑ Neff, Robert T.; Senter, Leigha; Salani, Ritu (August 2017). "BRCA mutation in ovarian cancer: testing, implications and treatment considerations". Therapeutic Advances in Medical Oncology. 9 (8): 519–531. doi:10.1177/1758834017714993. ISSN 1758-8340. PMC 5524247. PMID 28794804.
  11. 1 2 Huang, Yong-Wen (2018-01-12). "Association of BRCA1/2 mutations with ovarian cancer prognosis". Medicine. 97 (2): e9380. doi:10.1097/MD.0000000000009380. ISSN 0025-7974. PMC 5943891. PMID 29480828.
  12. ↑ Bansal, Anshuma; Singh, Mini P; Rai, Bhavana (2016). "Human papillomavirus-associated cancers: A growing global problem". International Journal of Applied and Basic Medical Research. 6 (2): 84–89. doi:10.4103/2229-516X.179027. ISSN 2229-516X. PMC 4830161. PMID 27127735.
  13. 1 2 Van Dyne, Elizabeth A.; Henley, S. Jane; Saraiya, Mona; Thomas, Cheryll C.; Markowitz, Lauri E.; Benard, Vicki B. (2018-08-24). "Trends in Human Papillomavirus–Associated Cancers — United States, 1999–2015". Morbidity and Mortality Weekly Report. 67 (33): 918–924. doi:10.15585/mmwr.mm6733a2. ISSN 0149-2195. PMC 6107321. PMID 30138307.
  14. 1 2 Collins, Stuart; Rollason, Terry P.; Young, Lawrence S.; Woodman, Ciaran B. J. (January 2010). "Cigarette smoking is an independent risk factor for cervical intraepithelial neoplasia in young women: A longitudinal study". European Journal of Cancer. 46 (2): 405–11. doi:10.1016/j.ejca.2009.09.015. PMC 2808403. PMID 19819687.
  15. ↑ Hussain, Shehnaz K.; Madeleine, Margaret M.; Johnson, Lisa G.; Du, Qin; Malkki, Mari; Wilkerson, Hui-Wen; Farin, Federico M.; Carter, Joseph J.; Galloway, Denise A.; Daling, Janet R.; Petersdorf, Effie W. (July 2008). "Cervical and Vulvar Cancer Risk in Relation to Joint Effects of Cigarette Smoking and Genetic Variation in Interleukin 2". Cancer Epidemiology, Biomarkers & Prevention. 17 (7): 1790–9. doi:10.1158/1055-9965.EPI-07-2753. ISSN 1055-9965. PMC 2497438. PMID 18628433.
  16. 1 2 3 Daling, Janet R.; Madeleine, Margaret M.; Schwartz, Stephen M.; Shera, Katherine A.; Carter, Joseph J.; McKnight, Barbara; Porter, Peggy L.; Galloway, Denise A.; McDougall, James K.; Tamimi, Hisham (2002-02-01). "A Population-Based Study of Squamous Cell Vaginal Cancer: HPV and Cofactors". Gynecologic Oncology. 84 (2): 263–270. doi:10.1006/gyno.2001.6502. ISSN 0090-8258. PMID 11812085.
  17. 1 2 3 Fonseca-Moutinho, José Alberto (2011). "Smoking and Cervical Cancer". ISRN Obstetrics and Gynecology. 2011: 847684. doi:10.5402/2011/847684. PMC 3140050. PMID 21785734.
  18. ↑ Xi, Long Fu; Koutsky, Laura A.; Castle, Philip E.; Edelstein, Zoe R.; Meyers, Craig; Ho, Jesse; Schiffman, Mark (December 2009). "Relationship between cigarette smoking and human papillomavirus type 16 and 18 DNA load". Cancer Epidemiology, Biomarkers & Prevention. 18 (12): 3490–6. doi:10.1158/1055-9965.EPI-09-0763. ISSN 1055-9965. PMC 2920639. PMID 19959700.
  19. ↑ Madeleine, Margaret M.; Daling, Janet R.; Schwartz, Stephen M.; Carter, Joseph J.; Wipf, Gregory C.; Beckmann, Anna Marie; McKnight, Barbara; Kurman, Robert J.; Hagensee, Michael E.; Galloway, Denise A. (1997-10-15). "Cofactors With Human Papillomavirus in a Population-Based Study of Vulvar Cancer". JNCI: Journal of the National Cancer Institute. 89 (20): 1516–1523. doi:10.1093/jnci/89.20.1516. ISSN 0027-8874. PMID 9337348.
  20. ↑ Mm, Madeleine; Jr, Daling; Jj, Carter; Gc, Wipf; Sm, Schwartz; B, McKnight; Rj, Kurman; Am, Beckmann; Me, Hagensee (1997-10-15). "Cofactors with human papillomavirus in a population-based study of vulvar cancer". Journal of the National Cancer Institute. 89 (20): 1516–23. doi:10.1093/jnci/89.20.1516. PMID 9337348.
  21. 1 2 "Risk Factors for Vaginal Cancer". www.cancer.org. Retrieved 2020-12-02.
  22. 1 2 S, Gurunath; Z, Pandian; Ra, Anderson; S, Bhattacharya (September 2011). "Defining infertility--a systematic review of prevalence studies". Human Reproduction Update. 17 (5): 575–88. doi:10.1093/humupd/dmr015. PMID 21493634.
  23. 1 2 Lundberg, Frida E.; Iliadou, Anastasia N.; Rodriguez-Wallberg, Kenny; Gemzell-Danielsson, Kristina; Johansson, Anna L. V. (2019). "The risk of breast and gynecological cancer in women with a diagnosis of infertility: a nationwide population-based study". European Journal of Epidemiology. 34 (5): 499–507. doi:10.1007/s10654-018-0474-9. PMC 6456460. PMID 30623293.
  24. 1 2 3 4 Funston, Garth; O’Flynn, Helena; Ryan, Neil A. J.; Hamilton, Willie; Crosbie, Emma J. (2018-04-01). "Recognizing Gynecological Cancer in Primary Care: Risk Factors, Red Flags, and Referrals". Advances in Therapy. 35 (4): 577–589. doi:10.1007/s12325-018-0683-3. ISSN 1865-8652. PMC 5910472. PMID 29516408.
  25. ↑ Gajjar, Ketan; Ogden, Gemma; Mujahid, M. I.; Razvi, Khalil (2012-08-23). "Symptoms and Risk Factors of Ovarian Cancer: A Survey in Primary Care". ISRN Obstetrics and Gynecology. 2012: 754197. doi:10.5402/2012/754197. ISSN 2090-4436. PMC 3432546. PMID 22957264.
  26. ↑ Pakish, Janelle B.; Lu, Karen H.; Sun, Charlotte C.; Burzawa, Jennifer K.; Greisinger, Anthony; Smith, Frances A.; Fellman, Bryan; Urbauer, Diana L.; Soliman, Pamela T. (2016-11-01). "Endometrial Cancer Associated Symptoms: A Case-Control Study". Journal of Women's Health. 25 (11): 1187–1192. doi:10.1089/jwh.2015.5657. ISSN 1540-9996. PMC 5116765. PMID 27254529.
  27. ↑ PDQ Adult Treatment Editorial Board (2002), "Endometrial Cancer Treatment (PDQ®): Patient Version", PDQ Cancer Information Summaries, Bethesda (MD): National Cancer Institute (US), PMID 26389334, retrieved 2020-11-20
  28. ↑ Kaltenecker, Brian; Tikaria, Richa (2020), "Vaginal Cancer", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 32644552, retrieved 2020-11-20
  29. ↑ PDQ Adult Treatment Editorial Board (2002), "Vaginal Cancer Treatment (PDQ®): Patient Version", PDQ Cancer Information Summaries, Bethesda (MD): National Cancer Institute (US), PMID 26389348, retrieved 2020-11-20
  30. ↑ Mishra, Gauravi A.; Pimple, Sharmila A.; Shastri, Surendra S. (2011). "An overview of prevention and early detection of cervical cancers". Indian Journal of Medical and Paediatric Oncology. 32 (3): 125–132. doi:10.4103/0971-5851.92808. ISSN 0971-5851. PMC 3342717. PMID 22557777.
  31. ↑ Ghurani, Giselle B.; Penalver, Manuel A. (2001-08-01). "An update on vulvar cancer". American Journal of Obstetrics and Gynecology. 185 (2): 294–299. doi:10.1067/mob.2001.117401. ISSN 0002-9378. PMID 11518882.
  32. ↑ Alkatout, Ibrahim; Schubert, Melanie; Garbrecht, Nele; Weigel, Marion Tina; Jonat, Walter; Mundhenke, Christoph; Günther, Veronika (2015-03-20). "Vulvar cancer: epidemiology, clinical presentation, and management options". International Journal of Women's Health. 7: 305–313. doi:10.2147/IJWH.S68979. ISSN 1179-1411. PMC 4374790. PMID 25848321.
  33. 1 2 Chandra, Ashwin; Pius, Cima; Nabeel, Madiha; Nair, Maya; Vishwanatha, Jamboor K.; Ahmad, Sarfraz; Basha, Riyaz (2019-09-27). "Ovarian cancer: Current status and strategies for improving therapeutic outcomes". Cancer Medicine. 8 (16): 7018–7031. doi:10.1002/cam4.2560. ISSN 2045-7634. PMC 6853829. PMID 31560828.
  34. 1 2 Cortez, Alexander J.; Tudrej, Patrycja; Kujawa, Katarzyna A.; Lisowska, Katarzyna M. (2018). "Advances in ovarian cancer therapy". Cancer Chemotherapy and Pharmacology. 81 (1): 17–38. doi:10.1007/s00280-017-3501-8. ISSN 0344-5704. PMC 5754410. PMID 29249039.
  35. 1 2 3 Schorge, John O; McCann, Christopher; Del Carmen, Marcela G (2010). "Surgical Debulking of Ovarian Cancer: What Difference Does It Make?". Reviews in Obstetrics and Gynecology. 3 (3): 111–117. ISSN 1941-2797. PMC 3046749. PMID 21364862.
  36. 1 2 Tangjitgamol, Siriwan; Manusirivithaya, Sumonmal; Laopaiboon, Malinee; Lumbiganon, Pisake; Bryant, Andrew (2013-04-30). Tangjitgamol, Siriwan (ed.). "Interval debulking surgery for advanced epithelial ovarian cancer". The Cochrane Database of Systematic Reviews. 4 (4): CD006014. doi:10.1002/14651858.CD006014.pub6. ISSN 1469-493X. PMC 4161115. PMID 23633332.
  37. ↑ Creasman, W. T. (December 1994). "Second-look laparotomy in ovarian cancer". Gynecologic Oncology. 55 (3 Pt 2): S122–127. doi:10.1006/gyno.1994.1350. ISSN 0090-8258. PMID 7835795.
  38. 1 2 Tomao, Federica; Di Pinto, Anna; Sassu, Carolina Maria; Bardhi, Erlisa; Di Donato, Violante; Muzii, Ludovico; Petrella, Maria Cristina; Peccatori, Fedro Alessandro; Panici, Pierluigi Benedetti (2018-12-06). "Fertility preservation in ovarian tumours". ecancermedicalscience. 12: 885. doi:10.3332/ecancer.2018.885. ISSN 1754-6605. PMC 6345054. PMID 30679952.
  39. 1 2 Šarenac, Tanja; Mikov, Momir (2019-06-04). "Cervical Cancer, Different Treatments and Importance of Bile Acids as Therapeutic Agents in This Disease". Frontiers in Pharmacology. 10: 484. doi:10.3389/fphar.2019.00484. ISSN 1663-9812. PMC 6558109. PMID 31214018.
  40. ↑ Emons, G.; Mallmann, P. (March 2014). "Recommendations for the Diagnosis and Treatment of Endometrial Cancer, Update 2013". Geburtshilfe und Frauenheilkunde. 74 (3): 244–247. doi:10.1055/s-0034-1368268. ISSN 0016-5751. PMC 4812876. PMID 27065482.
  41. 1 2 Denschlag, Dominik; Ulrich, Uwe; Emons, Günter (August 2011). "The Diagnosis and Treatment of Endometrial Cancer". Deutsches Ärzteblatt International. 108 (34–35): 571–577. doi:10.3238/arztebl.2011.0571. ISSN 1866-0452. PMC 3167060. PMID 21904591.
  42. 1 2 3 4 Sznurkowski, Jacek Jan (July 2016). "Vulvar cancer: initial management and systematic review of literature on currently applied treatment approaches". European Journal of Cancer Care. 25 (4): 638–646. doi:10.1111/ecc.12455. ISSN 1365-2354. PMID 26880231.
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  44. 1 2 3 Abbott-Anderson, Kristen; Kwekkeboom, Kristine L. (March 2012). "A systematic review of sexual concerns reported by gynecological cancer survivors". Gynecologic Oncology. 124 (3): 477–489. doi:10.1016/j.ygyno.2011.11.030. ISSN 1095-6859. PMID 22134375.
  45. ↑ Iżycki, Dariusz; Woźniak, Katarzyna; Iżycka, Natalia (June 2016). "Consequences of gynecological cancer in patients and their partners from the sexual and psychological perspective". Przegla̜d Menopauzalny = Menopause Review. 15 (2): 112–116. doi:10.5114/pm.2016.61194. ISSN 1643-8876. PMC 4993986. PMID 27582686.
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