Cancer

Cancer is one of the leading causes of death in women.1 The ageing female is at risk for endometrial, ovarian, breast, cervical, vulvar and vaginal cancer. Since there is risk with increasing age, reviewing the risk factors is important to help promote a good quality of life. Proper screening, early detection, treatment and management of comorbidities are essential.

Endometrial Cancer

Endometrial cancer is the fourth most common malignancy in women after breast cancer, colorectal and lung cancer. Peak incidence occurs in women between 50 and 60 years of age and the incidence appears to be climbing. The 5 year survival rate for all stages of endometrial cancer has been estimated at 65%.

Risk factors include nulliparity, obesity and prolonged use of unopposed exogenous estrogens. The most common symptom is postmenopausal vaginal bleeding.

Besides a physical examination and Pap smear, a pelvic ultrasonography and either an endometrial biopsy or dilatation and curettage (D & C) is required for diagnosis or exclusion of diagnosis of endometrial cancer. [a positive Papanicolaou (Pap) test for endometrial cancer will only show in 35–50% of the cases and should not be the only determinant in diagnosis.] Optimal treatment is a hysterectomy with bilateral oophorectomy and dissection of retroperitoneal lymph nodes in the pelvic and para-aortic region.2 Additional treatment, such as chemotherapy, radiation or both, may also be indicated in advanced stages of cancer and discussion is needed with the patient’s oncologist and geriatrician to weigh the risks against the benefits.

Ovarian Cancer

After endometrial cancer, ovarian cancer is the second most common gynaecological malignancy. Peak incidence occurs in women aged between 50 and 60 years. Risk factors included uninterrupted ovulation (nulliparity or contraceptive usage) and inherited genetic mutations.

Symptoms usually are non-specific. Abdominal pain, abdominal distension and gastrointestinal disturbances are complaints sometimes voiced by women with ovarian cancers, but symptoms may not develop until late in the disease process. Screening, except for high-risk patients, may include ultrasonography and tumour markers; however, it is thought to be of limited value.

Ovaries are generally small and not palpable in postmenopausal women and if upon physical examination an ovary is able to be palpated, immediate evaluation is warranted since it is suggestive of ovarian cancer. Initial treatment involves surgical removal of the tumour. Chemotherapy may be considered depending on the tumour stage, the patient’s comorbidities and benefits versus risks. Since most ovarian cancers are detected when the tumour is advanced, long-term prognosis is usually poor.

Breast Cancer

Approximately 50% of all new breast cancer cases occur in women over the age of 65 years. The incidence of breast cancer increases up to the age of 80 years, levels out between the ages 80 and 85 years and then is thought to decline. It is difficult to evaluate those over 85 years of age owing to limited data. Risk factors for developing breast cancer may include personal or family history of breast cancer and/or colon or endometrial cancer in the first-degree relatives, nulliparity or late first pregnancy at 31 years of age or older, late menopause, early menarche, abdominal obesity, estrogen replacement therapy and history of atypical hyperplasia on biopsy for benign breast disease.3

Screening for breast cancer in a postmenopausal woman includes monthly self-breast examinations, an annual physical examination by a physician or other healthcare provider and a mammogram, yearly or every 2 years. Research has shown that screening for breast cancer in women aged 50–70 years has improved survival by early detection. There are many doctor s who feel that mortality could be reduced by 25–30% if all women received proper mammographic screening. There are limited data on breast screening in women over 70 years of age, but it is though that mammography is of benefit. Since 10–20% of all breast cancers are not picked up on mammography, physical examination is also important.

Fewer than 50% of all women aged 65 years or older have ever had a mammogram and those who have obtained one on a routine basis. There has been argument by physicians against instituting routine screening for breast cancer in elderly women, stating that disability and shorter life expectancy may have a direct effect on the desirability and cost-effectiveness of screening. On the other hand, the life expectancy of a healthy woman in her mid- to late-70s is approximately 10 more years and for a healthy woman 85 years of age it is 7 more years. Hence screening appears to be warranted.

The clinical characteristics of breast cancer are the same, despite the age of the individual. Cancer is generally suspected when breast lesions palpated feel firm or abnormalities are detected on mammography. A palpable breast mass in a postmenopausal woman requires immediate attention, since most palpable masses are malignant. All breast masses in this age-group should have a biopsy whether the mass was palpated and/or detected on mammography.

Prognosis is determined by the stage of the disease. Owing to lack of clinical studies, it is unclear whether women over the age of 65 years have the same clinical course as younger women. The course of treatment is prompted by the stage of the disease. Until recently, many elderly women with breast cancer were not aggressively treated; however, today many older women are working with their oncologists and geriatricians discussing various treatment options.

Cervical Cancer

Cervical cancer occurs in women of all ages but its incidence peaks in women 40–50 years of age.4 Symptoms may vary and hinge on the stage of the tumour. Some women may be asymptomatic, whereas others may show clinical signs of postmenopausal or postcoital bleeding. Routine Pap testing is the best method of screening. If the Pap testing is positive, colposcopy-directed biopsies and endocervical curettage are used to establish diagnosis.

Radical hysterectomy is the recommended treatment for cervical cancer. Adjuvant radiation or chemotherapy may also be used. The combined cure rate for cervical cancers is 50–60%.

Vulvar Cancer

Vulvar cancer accounts for approximately 3–4% of all gynaecological malignancies in the USA.5 The average age at diagnosis is 70 years and the incidence increases with age. The most common symptoms exhibited in vulvar cancer are vulvar pruritus, pain and a palpable vulvar lesion; however, many women are asymptomatic.6 A discharge may be present. Histology generally reveals squamous cell carcinoma. Biopsy may be indicated for diagnosis. Treatment is generally surgical and, for extensive lesions, a radical vulvectomy with unilateral or bilateral inguinal lymphadenectomy is recommended. Radiation and chemotherapy may also be considered adjuvant therapy. Prognosis for early-staged lesions is generally favourable. The 5 year survival rate is 80–90% if there is no metastasis to the lymph node and 16–30% if lymph node metastasis is present.

Vaginal Cancer

Vaginal cancer is relatively rare.7 The average age at diagnosis is 60–65 years. It is estimated that 95% of these lesions are squamous cell carcinomas. Vaginal bleeding or discharge is an early symptom. Pain or post-coital bleeding may be exhibited in sexually active women. Where the tumour involves the anterior vaginal wall, it may cause dysfunction with voiding, since the vaginal wall may invade into the urethra. Biopsy is indicated for diagnosis. Radiation is the main choice of treatment; however, surgery and chemotherapy may be utilized in specific cases. Prognosis is dependent upon the size and location of the tumour. The 5 year survival rate for all types is estimated to be 25–48%.

Menopause

Menopause is the permanent cessation of menses as a result of ovarian ageing. It is clinically diagnosed after 12 months of amenorrhoea. The average age in the USA at which menopause occurs is 51 years. The perimenopausal transition is defined as the time prior to permanent cessation of menses and is identified with irregular menstrual cycles. Transitional time has been shown to vary in length from 2 to 8 years.

Early symptoms of menopause include irregular menstrual cycles, headaches, fatigue, changes in mood and cognition, insomnia and hot flashes (Table 129.1). Some women may experience vertigo, heart palpitations and tachycardia. A later clinical presentation may include urinary incontinence, dry skin, breast changes, genital atrophy with dyspareunia, vaginitis and cystitis.

Table 129.1 Signs and symptoms of menopause.

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