Key Clinical Questions
How do the different treatment modalities for cancers unique to women put patients at risk for future complications?
What is the initial evaluation and treatment of these complications?
Which complications require emergent consultation?
While many cancers have similar medical complications that require hospitalizations, cancers specific to women, breast and gynecologic cancers, often have unique medical presentations. In this chapter, we will discuss common presentations, diagnostic workup, and treatment for complications that may arise during treatment or surveillance for breast and gynecologic cancers. Since many of the issues that impact ovarian and endometrial cancer patients are similar, the topic will speak mostly toward complications for women with ovarian cancer. In addition, since chemoradiation is a primary treatment for cervical cancer, complications related to cervical cancer treatment will be reviewed; these issues are relevant and similar for women treated for vulvar or vaginal cancers.
In the United States, breast cancer is the most commonly diagnosed cancer among women and the second most common cause of cancer death. Generally, the mainstay of treatment is surgical, typically with breast conservation therapy (BCT) for women with early-stage disease, which consists of a lumpectomy followed by radiation therapy (x-ray therapy [XRT]). However, some women will undergo a modified radical mastectomy due to tumor size or patient preference. With rare exceptions, women with invasive carcinoma (and those women undergoing mastectomy for ductal carcinoma in situ [DCIS]), will have nodal evaluation.
Management of the axilla continues to evolve. Traditionally, patients with a positive sentinel lymph node would undergo an axillary lymph node dissection. Randomized clinical trials directly comparing BCT with mastectomy have shown equivalent survival between the two treatment approaches. The American College of Surgeons Oncology Group (ACOSOG) Z11 trial showed that in selected patients with one to two positive sentinel nodes, a sentinel lymph node biopsy (SLNB) can obviate the need for an axillary lymph node dissection (ALND). More recently, the EORTC (European Organization for Research and Treatment of Cancer) AMAROS trial reported that in patients with a T1-2 primary breast cancer, no palpable lymphadenopathy and with a positive sentinel node, axillary radiotherapy is noninferior to axillary lymph node dissection in controlling 5-year axillary node recurrence.
The use of postoperative (or adjuvant) systemic therapy is guided by the patient’s clinical status, tumor characteristics, and more and more, the genomic characteristics of the tumor. Patients with hormone receptor (estrogen/progesterone)-positive malignancies are candidates for endocrine therapy such as the selective estrogen receptor modulator, tamoxifen, or aromatase inhibitors. However, genomic tests, such as the Recurrence Score, may be used to predict prognosis for women treated with endocrine therapy and therefore identify higher-risk patients who should be offered chemotherapy. Patients with human epidermal growth factor receptor 2 (HER2)-positive cancers should receive therapy that includes HER2-directed treatment (trastuzumab, pertuzumab). Patients with triple negative breast cancer will also receive cytotoxic chemotherapy. Febrile ...