Abstract
The 7th Annual Women's Cancer Conference November 2007, Las Vegas, Nevada, USA
The 7th Annual Women's Cancer Conference, cosponsored by the City of Hope (CA, USA) and the Nevada Cancer Institute, USA, convened in November 2007 at the Wynn Hotel in Las Vegas, Nevada. Lucille Leong and Robert Morgan, both from the City of Hope faculty, co-chaired the Women's Cancer Conference and were pleased with the 260 attendees, 20% of whom had attended a prior Women's Cancer Conference. The 3-day Women's Cancer Conference is primarily directed towards the general oncologist and primary care physician seeking a more in-depth understanding of new cancer treatments and practice. The presenting faculty for the 2007 meeting came predominantly from the two host institutions, with additional speakers from around the USA. The Women's Cancer Conference follows a case-based learning format: didactic lectures are followed by a series of individual case presentations, which are discussed in detail with full audience participation.
It is estimated that over 680,000 women in the USA will develop cancer in 2007 and almost 290,000 will die of the disease. Although a decline in the use of menopausal hormone therapy has resulted in a decline in new breast cancers, breast cancer remains the most common malignancy to develop in women. Improvements in screening and therapy have been credited with the improved survival of women with early stage disease. In the USA, the leading causes of cancer-related deaths are lung, colorectal, pancreas and ovarian cancers. Worldwide, cervical cancer is a major cause of cancer mortality.
The first day of the conference focused on the interdisciplinary approach to gynecologic malignancies. Lectures from oncologic surgeons, medical oncologists and pathologists highlighted the diagnosis and treatment of cervical and ovarian cancers. The human papilloma virus (HPV) is an oncogenic virus and a causative agent in cervical cancer. HPV is isolated in over 99% of all cancer specimens. The WHO has declared HPV to be the first identified ‘necessary cause’ of a human cancer. Although the routine use of PAP smears has decreased the incidence and death rate in ‘resource rich’ countries, worldwide cervical cancer continues to be a leading cause of cancer death in women.
After reviewing the role of HPV in the pathogenesis of cervical cancer, Sharon Wilczynski summarized diagnostic testing for HPV. The Canadian Cervical Cancer Screening Trial compared conventional cervical cytologic testing (PAP) with FDA-approved HPV DNA testing in a population of 10,154 women aged 30–69 years who presented for routine screening. The HPV DNA test was more sensitive than the PAP –94.5 compared with 55.4% and negative predictive values of 99.8 and 100%. A Swedish trial enrolled 12,527 women to PAP alone or to HPV DNA testing (PCR-immunoassay that is not FDA approved) plus PAP. Grade 2 or 3 cervical intraepithelial neoplasia (CIN) or cancer was identified in 51% more women undergoing both tests. However, the increased sensitivity of the HPV DNA test resulted in many more additional tests and cancer diagnoses. CIN was ‘overdiagnosed’ in this trial, as many of the CIN grade 2 lesions spontaneously regressed and would have gone undetected were it not for the HPV DNA test. While there is no uniform consensus on HPV testing, the American Cancer Society supports the use of HPV DNA testing with cytology for screening women over the age of 30 years. The increased sensitivity of these two tests justifies increasing the screening intervals to 3 years. The majority of cervical cancers are associated with the 16 and 18 serotypes of HPV and the development of a vaccine provides an opportunity to prevent the majority of cancers caused by this virus. The FDA has approved HPV vaccination in females aged 9–26 years of age for prevention of cervical cancers caused by the viral serotypes 6, 11, 16 and 18.
The second morning was largely devoted to the management of breast cancer. A diverse series of topics included adjuvant endocrine therapy, chemotherapy for advanced disease, advances in radiation oncology, treatment of breast cancer in the elderly, heritable and health management issues of the breast cancer survivor. Approximately 5–10% of breast and ovarian cancers have a hereditary basis. Jeffrey Weitzel, Director, Department of Clinical Cancer Genetics at City of Hope, discussed the expanding role of genetics counseling in disease management and prevention. Women who develop breast cancer at an early age (<40 years), have bilateral disease, or have a family history of male breast cancer, breast and/or ovarian cancers should be considered candidates for genetics counseling. The knowledge that a patient has a BRCA mutation is increasingly being used to guide treatment decision-making. These women may elect to undergo prophylactic surgeries (bilateral mastectomy or bilateral oophorectomy) or may require more vigilant surveillance. Genetics testing of at-risk family members may be important in developing preventive strategies or modifying breast cancer surveillance through the use of MRI imaging. Cancers that arise in BRCA mutation carriers have a diminished capacity for DNA repair. The poly (ADP-ribose) polymerase (PARP) inhibitors have been shown to have activity in preclinical models and are presently in clinical testing in women who have BRCA1/2 mutations and advanced breast cancer. Cancer genetics is an exciting and rapidly changing subspecialty in the management of breast cancer and other malignancies.
On the third and final day of the conference, Mark Moyad, the Phil F Jenkins Director of Complimentary Medicine at the University of Michigan Medical Center, spoke on ‘Diet & dietary supplements from A–Z: what works and what is useless'. In the USA, over 30 billion US dollars are spent annually on complimentary and alternative medication. Dr Moyad emphasized the need to review the evidence-based data for using such remedies, as many can adversely affect health. Dr Moyad cautioned that even the use of daily multiple vitamins should be scrutinized, citing the NIH–AARP Diet and Health Study that identified a higher risk of advanced and fatal prostate cancers in men who regularly took multiple vitamins.
It is also important that complimentary alternative medications be assessed separately in women. While taking aspirin daily is recommended in men, women do not derive the same benefits. The Women's Health Study, which included over 39,000 women, found that a daily dose of aspirin reduced heart attacks and ischemic strokes in women over age 65 years, but increased hemorrhagic stroke, gastrointestinal bleeding and peptic ulcer disease. Although the use of calcium and vitamin D supplementation failed to prevent colorectal cancer in the Women's Health Initiative both are essential for normal health. Aging and sunscreen use contribute to making Vitamin D the number one nutritional deficiency in this country. Measurement of 25-hydroxy Vitamin D provides the best assessment of Vitamin D stores and levels of 40 nmol/1 or more are considered to be adequate. Although ergocalciferol (D2) is most commonly used as a supplement, cholecalcoiferol (D3) will increase blood levels most effectively.
The most important lifestyle change that impacts on disease is exercise. Evidence-based data support the importance of exercise in decreasing the incidence of premature death, heart disease, stroke, Type 2 diabetes, breast cancer, colon cancer and osteoporosis.
Other topics that were covered during the conference included a review of hereditary colorectal cancer syndromes, and the role of surgery, adjuvant chemotherapy and the new targeted agents in treating colorectal cancers. Alexandra Levine reviewed HIV-associated malignancies in women. Lucille Leong presented an extremely well received discussion on the importance of cultural competence in managing patients with cancer. Benjamin Paz, oncologic surgeon, and Robert Morgan, medical oncologist, reviewed the role of surgery and intraperitoneal chemotherapy in the management of nongynecologic intraperitoneal malignancies.
Summary
The 7th Annual City of Hope Women's Conference included a number of experts in a variety of oncologic subspecialties. The 3-day conference covered a diverse range of topics from new and aggressive treatment modalities to the management of the cancer survivor. The case discussions produced lively interactions between the attendees and the presenting faculty. In summary, this is an excellent conference for primary care physicians, practitioners and general oncologists who are seeking a balanced perspective regarding new cancer treatments and practical information regarding the treatment and follow-up care of women with cancer.
Future perspective
Women who have been treated for cancer develop unique medical problems that may be related to medical intervention. It is critically important that physicians and patients focus on the evidence-based outcomes of both the medical intervention and patient self-prescribing. A healthy diet and regular exercise contribute to the quality of life of cancer patients. Attention should be paid to aging health problems including symptoms of menopause and bone health.