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13 April 2010

Gunnar Kristensen, of the Nordic Society of Gynaecological Oncology, examines the challenges in successfully treating the most frequent of cancers affecting women in the region

In a global perspective, cancer of the uterine cervix is the most frequent cancer affecting women, giving rise to a lot of suffering. With HPV vaccination, the number of affected women can be substantially reduced. Unfortunately, countries with the most patients are the poorest – with scarce resources for population-based vaccination programmes. In the Nordic region, the incidence of cervical cancer is low due to effective screening programmes and will be further reduced in the future due to national-funded HPV vaccination programmes.

For women diagnosed with cervical cancer, those with small tumours can be effectively treated with surgery and often have the option to preserve their fertility.

Long lasting side effects are rare. Women with more advanced cancer are treated with radiation together with chemotherapy, but unfortunately, radiotherapy has inherently unpleasant side effects. Studies are ongoing to optimise radiotherapy to achieve better cures and less long-term side effects. Also, women with advanced cervical cancer often have tumour cells that have spread outside the area that can be reached by radiation. Such radiation treatment prevents relapses in the pelvis, but does not decrease the risk of dying from such a relapse.

The possibility to eradicate these cells with additional chemotherapy will be the focus of a forthcoming academic study run independent from industry. In a recent study (Lando et al. PLoS Genet 5(11)), a number of genes were found to be related to the aggressiveness of the tumour. Developing drugs that can block these genes may prove helpful.

In cancer of the uterine body, a recent Nordic study showed that chemotherapy in addition to radiation did decrease the risk of death. The present challenge is partly to evaluate whether radiation is needed at all in this setting and partly to identify the subgroup of patients who will benefit from chemotherapy. The extent of surgery is also an open question. These questions will be dealt with in European academic studies.

Ovarian cancer is the deadliest of the gynaecologic cancers, with a five-year survival rate of only 42%. These tumours are often diagnosed in a late and advanced stage due to few and vague symptoms. When diagnosed at an early stage, the five-year survival figure is about 80%. Much effort has been spent trying to find efficient methods for screening to be able to diagnose the tumours at an earlier stage, but so far without success. Surgery with removal of all visible tumour elements is the first step in the treatment. These tumours often spread into the abdominal cavity and affect the intestines, making it difficult or impossible to remove all tumour elements by surgery. Chemotherapy is thus a very important part of the treatment. Ovarian cancer usually responds well to chemotherapy, but unfortunately some tumour cells often survive the treatment and give rise to a later relapse with tumours consisting of cells being partly or completely resistant to chemotherapy. To achieve a better cure, we need to develop medicines that target some vital functions within the tumour cells to be able to kill the cells, either by drugs alone or in combination with chemotherapy.

The pharmaceutical industry invests a lot of money in developing drugs. For obvious reasons, diseases that affect many patients have the highest priority and it is difficult to persuade industry to invest in rare diseases, and even more difficult to get funding for academic studies of the kind mentioned above. The Nordic and most European countries do not give support at all, and it is also very difficult to get support from the European Union. So, being dependent on the industry for development is a very unfortunate situation. It is my hope that responsible politicians will take notice, and action.