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Transcript
Katherine Banwell:
Hello, I’m Katherine Banwell, your host for today’s webinar. Today, we’ll be talking about the importance of gynecological cancer screening and detection. We’ll talk about when and how to get screened, explore new research advances, and discuss proactive steps to help overcome the barriers that sometimes prevent women from seeking care. Before we meet our guest, let’s look at a few important reminders. The email you received about this webinar contains a link to a program resource guide. If you haven’t already, click that link to access information to follow along during the webinar. At the end of this program, you’ll receive a link to a survey. Please take a moment to share feedback about your experience today in order to help us plan future webinars. Finally, before we get into the discussion, please remember that this program is not a substitute for seeking medical advice. Please refer to your health care team about what might be best for you.
Well, let’s meet our guest. Joining us today is Dr. Heidi Gray. Dr. Gray, thank you so much for being with us. Would you introduce yourself?
Dr. Heidi Gray:
Yes, thank you so much for having me again. Nice to see you. My name is Heidi Gray. I am a gynecologic oncologist here at University of Washington and Fred Hutch Cancer Center. I serve as our director of clinical trials at the Hutch, as well as the GYN surgical services at University of Washington.
Katherine Banwell:
Thank you. I’d like to start by you telling us what areas of research you’re involved in.
Dr. Heidi Gray:
Yeah, so I care for women with gynecologic cancers. It expands the range of all the cancers of the gynecologic tract. So, the uterus or endometrium, the ovaries, fallopian tubes, cervix, vagina, and vulva. So, my research has mostly been focused on improving and access to clinical trials in a variety of these cancers.
Katherine Banwell:
Before we start talking about screenings and detection, I’d like to start by understanding the basics. What does it mean when we talk about gynecological cancers? What types of cancers are involved?
Dr. Heidi Gray:
Yeah, so the cancers of the gynecologic tract encompass GYN oncology. So, cancers of the uterus, ovaries, fallopian tubes, cervix, the vagina, and the vulva.
Katherine Banwell:
Okay, and why is detection such a powerful tool in preventing more advanced disease?
Dr. Heidi Gray:
Yeah, that’s a great question. So, we know that when we detect cancers at an earlier stage or time in their development, that they always are more curable and more treatable. So, there’s a lot of focus on earlier detection of cancers, to be able to find them at an earlier time in their course, which will make them much more treatable and curable.
Katherine Banwell:
Mm-hmm.
Dr. Heidi Gray:
In addition, there’s also the role of screening. And screening is really looking at methods that detect cancer before it’s become cancer, or it’s precancerous, or in a state before it has turned into cancer. And that, of course, is very important because if you detect a patient or a disease before it’s become into cancer, then, of course, it is much more treatable and curable.
Katherine Banwell:
You’ve mentioned screening, and we’ve talked about why catching these cancers early is so important. I’d like to move on to how they’re detected. What are the current recommended screening guidelines for cervical, ovarian, uterine, and other gynecological cancers?
Dr. Heidi Gray:
Yes, so cervix cancer has been the most developed in terms of our understanding of how this cancer develops. And therefore, we’ve established really powerful tools to screen for precancerous states and prevent it from ever becoming cancer. Most notably, that most women know, is the Pap smear or Pap test – it is more commonly known. In addition, we know that the vast majority of cervix cancer is caused by a virus called HPV. And so, our screening detections of precancer for cervix entails screening both with a Pap test and with HPV.
Katherine Banwell:
So, how effective are tests like Pap smears and HPV testing, and even pelvic exams, at detecting cancer in its early stages?
Dr. Heidi Gray:
Yeah, so, incredibly effective. So, for cervix cancer, when you detect it before it’s become cancer – or what we call dysplasia or precancer – it can be treated either with minimal intervention or minimal harm to the patient and still preserve things like fertility and all of those other important issues for many women.
And it basically, if you fully treat something before it’s become precancerous, then the risk of it becoming cancer is essentially zero.
Katherine Banwell:
Are there patient-specific factors that can adjust the screening guidelines?
Dr. Heidi Gray:
There are, again, let’s talk a little bit about specifically cervix cancer prevention. So, the cervix cancer screening right now is age-related or age-focused. So, we recommend initiating screening with Pap tests at age 21 and then continuing that on for three years until age 29, where then we recommend dual testing with Pap tests and HPV testing every five years until age 65. There is a caveat that there was a new addition to adding HPV testing a little bit earlier. So, at age 25, women could also engage in HPV testing as a screen every five years, and then, as stated before.
So, age-related, because we know that it takes a fair amount of time with exposure to HPV before it turns into precancer or true cancer.
Katherine Banwell:
Dr. Gray, would you take a moment and define HPV for us?
Dr. Heidi Gray:
Yeah, yeah. HPV stands for human papillomavirus. So, it’s a virus that’s very common in humans. It’s found in men and in women. It’s ubiquitous, meaning it’s found – people are exposed to this kind of everywhere. And for most folks, when you’re exposed to HPV, your body can clear it or get rid of it, and it doesn’t cause any harm or disease. In a small portion of patients, however, the HPV lingers in the cells in the body, and in that group of patients, they can be at risk of developing precancer or cancer, particularly of the cervix. But also, HPV is related to cancers of the head and neck.
Katherine Banwell:
Okay, thank you for that.
Dr. Heidi Gray:
Mm-hmm.
Katherine Banwell:
Does the yearly well-woman exam cover detection well enough?
Dr. Heidi Gray:
Mmm, yeah, that’s a great question. I personally think that well-woman exams are very important. They cover a variety of topics. Obviously, my area of focus is on assessing and screening for risk of cancer, but there’s a lot of other very, very important topics that get covered during that visit. But particularly for the focus of finding, detecting either precancer or screening for cancer risk, parts of the well-woman exam – a lot of it is informational. So, conversational, asking questions with the patient, screening for symptoms, talking about family histories, or screening for family histories of cancer, and assessing risk of cancer in families or genetic risk. And then, additionally, the physical exam does usually entail a pelvic exam where the female organs are evaluated and assessed in a very safe manner.
Katherine Banwell:
Mm-hmm. What is hereditary or genetic testing, and where does it fit into the overall detection?
Dr. Heidi Gray:
Yeah, so, we know that a portion of all types of cancers may have a hereditary component or a genetic component, in which there is a gene or a mutation in a gene that’s passed along in families that puts that individual at risk of developing a cancer more so than the general population. And it’s important to note that when patients do have a genetic mutation or a risk of cancer, it’s not 100 percent. It’s not that, for the most part, that it just increases your risk of getting that cancer. And so, in particular, for gynecologic cancers, the most commonly known about genetic risk are in ovarian cancer. So, there’s a couple of very important mutations called BRCA1 and BRCA2, that are found that, in patients or families that have these mutations, they have markedly increased risk of both breast and ovarian cancers.
And so, it’s very important to detect those individuals and screen patients for this genetic risk, because we can intervene both with improved or increased screening and potentially surgical intervention to prevent either of these cancers from happening.
Katherine Banwell:
Well, how can a patient find out if they have a genetic mutation?
Dr. Heidi Gray:
Yes, that’s really important. So, there are a variety of different genetic tests available. It usually starts with kind of having a conversation with your provider or clinician about your own concerns or your risks or genetic risks. And a lot of that has to do with taking a very thorough family history, because we know that in families that have inherited risks for cancer – genetic risks – you see increased risk of cancers in those families. Now, sometimes people have smaller families, sometimes folks are adopted, or don’t know their family history.
So, sometimes the family history isn’t quite as informative. And some of us out there in the cancer community actually kind of really believe that probably all patients deserve some cancer screening or testing. It used to be extraordinarily expensive to do genetic testing and screening, which is typically a blood test. I mean, it was thousands and thousands of dollars. Actually, there are now commercially available tests that you can send in a cheek swab into some of these companies that do very, very intense genetic testing and screening. And honestly, I advocate for patients to consider that if they have any risk or worry. But it’s also important to kind of talk to your providers about.
Katherine Banwell:
Mm-hmm. Dr. Gray, for cancers that don’t have a regular screening test, like ovarian cancer, what can women do to stay vigilant?
Dr. Heidi Gray:
Yeah, that’s an important question. So, as you alluded to, ovarian cancer, which is one of our most kind of threatening cancers, it’s very hard to detect at an early stage. And we don’t have a reliable screening method to detect either precancer or pre-ovarian cancer, or even early-stage ovarian cancer. The two most common methods we use are a blood test, called a CA 125 – okay – which is what we call a tumor marker that can be elevated in ovarian cancers. And then the other tool we use is pelvic ultrasounds, which look at the gynecologic organs, particularly the uterus, the tubes, and the ovaries. These tools we use in a screening method for patients who do have a higher known risk of ovarian cancer. So, as I talked about before, patients who have the BRCA1 or 2 mutation or have a strong family history of either breast or ovarian cancer.
So, we don’t use them in just the general population because actually, some pretty large studies have found that even when we applied it to patients who didn’t have a higher risk of genetic – of ovarian cancer – to a general population, that we didn’t detect cancer at an earlier stage, which is super frustrating.
There’s a lot of interest now in looking at blood-based tests to look for screening of precancer, particularly with something called ctDNA, which is detecting either tumors or markers of cancer in the blood well before you would detect them on an image or have symptoms from it. The technology is still being developed, so we don’t really know how to apply it yet, because there sometimes can be what we call falsely positive results – where a result comes back as positive, but it isn’t truly a risk – or falsely negative – where a patient is reassured that they don’t have a risk when they might.
So, but I think that it’s really an exciting time because I do think that we will be coming to a point where we will be able to screen folks at much earlier stages for a variety of different cancers.
Katherine Banwell:
What early warning signs or symptoms should women never ignore?
Dr. Heidi Gray:
Mmm, yeah, very important. So, I would say one of the most important symptoms is bleeding after menopause in women. So, menopause is when your periods stop, and it usually happens around age 50 to 52 for most women. After that time, when periods stop and the bleeding has stopped, any bleeding that comes after that really needs to be paid attention to and should not be kind of ignored or thought of, “Well, this will pass.” So, we really encourage anytime women after menopause have had bleeding or spotting, or discharge that doesn’t go away to please seek out their provider.
Because when that does happen, we do recommend testing, such as a pelvic ultrasound, looking at the uterus, tubes, and ovaries. In addition, sometimes requires a biopsy or a sampling of the uterus.
Katherine Banwell:
Mm-hmm.
Dr. Heidi Gray:
So, bleeding is definitely one of the most important things. And then, I think, for ovarian cancer, patients who develop ovarian cancer do develop symptoms. I think there’s a lot of misinformation out there that patients who develop ovarian cancer would never have symptoms, and all of that. I think what we know about the symptoms is that they can be a little more subtle. And patients do need to be aware that things like, for example, bloating, which is kind of that sensation of kind of full intestines – everyone experiences bloating every once in a while – but abnormal bloating would be having that sensation over a period of two weeks – 10 days to two weeks – that doesn’t abate.
That would definitely be something that should trigger a visit to a provider to get more testing. In addition, changes to your bladder or how you void or urinate – not just like a one-time irritation, but over time, if you’re finding how you urinate or how your bladder is behaving – can be a subtle sign of ovarian cancer.
Katherine Banwell:
Are well-woman exams necessary to keep up post-menopause?
Dr. Heidi Gray:
Oh, yes. That’s such a great question. Absolutely. I think a lot of women engage with their providers during kind of the childbearing years because they’re having periods, sometimes having pregnancies. And so, there’s a lot more interaction with the medical community. And then sometimes after menopause, a lot of women are like, “Why do I need to go see my doctor? I feel fine, I’m not having any symptoms.” But it’s actually really important.
We know that the vast majority of cancers happen to women in the post-menopause state. So, women in their late 50s to 60s. And so, it actually is a really critical time to keep engaged with your providers. And going into well-women exams, talking about symptoms, having a physical exam, a pelvic exam, and really to make sure that you’re getting the care and potential screening that you need.
Katherine Banwell:
Yeah. If women feel something isn’t right after testing results come back normal, how can they discuss their feeling – probably an intuitive feeling – with their doctor, and then encourage further testing?
Dr. Heidi Gray:
Yeah, that’s also an important question. So, it can be really frustrating sometimes when you feel like something’s not going well or you have some symptoms that are maybe more vague, and you see your provider. And they do some testing and say, “Oh, the blood test looks fine, your exam is fine.”
So, I would really encourage patients to be advocates. I really listen to patients. It’s really important. You know your own body more, by far, than anyone else. And if you feel like something’s changing, you’re not right, ask for a second opinion. Ask about – are there any additional testing? “I’ve never had an ultrasound. How do I know, or –” be an advocate for yourself. I think sometimes busy practitioners don’t always – and if they’re only seeing you once a year, they only see you for a small sliver. So, I think important to be an advocate. And if you’re continuing to have symptoms and you feel like you’re not being listened to, seek out another opinion, and just be a strong advocate for yourself.
Katherine Banwell:
Dr. Gray, you’re a researcher, so you know that research is moving very quickly.
Dr. Heidi Gray:
Mm-hmm.
Katherine Banwell:
For cancers like ovarian cancer, where early detection is very challenging, what new research or tools are showing promise?
Dr. Heidi Gray:
Yeah, so, I think that what we really are looking for, and where the research is going, is developing some of these blood testings – also called, multi-cancer detection panels – that are looking at trying to screen for aspects of kind of precancer, or proteins in the blood that might put a patient at risk, or herald a sign of either an early or a precancerous state. Again, it’s really in development still. So, there is a lot of interest. There’s a pretty large trial – I believe it’s called the Vanguard trial – that’s ongoing at the NCI, or National Cancer Institute, that is enrolling patients that are asymptomatic – so not known cancer – and looking at some of these multi-cancer detection assays. I believe it’s about seven or nine sites recruiting across the country. Fred Hutch isn’t a site right now, but I believe the VA might be a site soon.
But I would encourage folks, if they’re interested in joining and participating in one of these studies, to go on the website – the NCI – and I believe it’s called the Vanguard Study.
Katherine Banwell:
Okay, good advice. Thank you. What about artificial intelligence? How is it impacting testing and early diagnosis?
Dr. Heidi Gray:
Yeah. So, yeah. I mean, artificial intelligence, as we know, is really kind of revolutionizing a lot of different aspects of our lives. And in oncology, where it’s mostly being utilized, is in improving screening for things like mammograms or CT scans, as an aid to better detect cancer or precancer, or abnormalities. In the cervix cancer space, AI is also being developed to use to better screen Pap tests – to look for abnormalities or cellular abnormalities. So, those are kind of the main areas that it’s definitely having an impact.
And again, I think that there’s an important role in the future of AI being able to screen or give people a better assessment of their risk of cancer, or their genetic risk of cancer, based on some of their medical history or background.
Katherine Banwell:
How do researchers learn about gynecological cancer detection? Are there observational studies that people can join?
Dr. Heidi Gray:
Yeah, that’s a great question. In the past, there have been a number of observational studies. I don’t believe we have any open right now here at the Hutch. But if folks are interested, one of the best sites usually is – either you can go to the Fred Hutch cancer website and say, interested in a trial to see observational studies. Sometimes that involves screening blood work or doing some surveys and follow-up.
Many of our studies right now are focused on folks that have higher risk of cancer – so, higher risk of breast or ovarian cancer – and following them over time to see when earlier intervention may be helpful.
Katherine Banwell:
Dr. Gray, how does treatment for early-stage gynecological cancer compare to those that are detected later, like ovarian cancer?
Dr. Heidi Gray:
Yeah. So, all cancers are much more treatable and have potential cure when they’re caught at an earlier stage. So, for example, with ovarian cancer, the vast majority of patients, when they are diagnosed, are diagnosed when the cancer has spread outside the ovary, or what we call kind of advanced stage. Most ovarian cancer is treated with surgery – either upfront or after chemotherapy. Most of the time, it’s detected at the time of surgery.
And almost always after surgery, we do recommend chemotherapy as a way to either prevent cancer from coming back or to treat any cancer that’s still present at the time. But again, the survivability of ovarian cancer, when it’s caught at an early stage, is just much more promising than at a more advanced stage. And so, definitely all of us in the oncology field would, of course, like to either detect before there’s ever cancer – but if you can detect cancer at an earlier stage, it’s incredibly important.
Katherine Banwell:
You know, Dr. Gray, unfortunately, many women can sometimes delay or neglect their own screening visits. Can you talk about some of the common barriers that prevent women from undergoing cancer screening?
Dr. Heidi Gray:
Yeah, that’s a really important question. I think that for some women, some of the barriers can be being embarrassed, particularly if they have a symptom, maybe they’ve not paid as much attention to.
One example I can think of is, sometimes women can develop sores or growths on the vulva, and people can be kind of embarrassed about bringing that up. It’s not an area most folks feel comfortable talking about or bringing attention to, and they are worried about the provider not maybe being as sensitive – or also worry about needing to have a test, like a biopsy, which can be painful. Other barriers can be some harms that they may have, and biases that they have encountered before with other providers. Maybe they saw a provider who treated them poorly or didn’t listen to what they were saying, and so they’re thinking, “Why am I going to go spend money to go see this person who isn’t going to really listen to me or treat me with respect?” So, I think that those are definitely some important barriers that we need to, as providers, make sure that we’re aware of – particularly around the sensitivity of pelvic exams and the trauma that many people have around pelvic exams.
So, it’s really important, as a provider, to make sure you provide a very safe space for patients and have a conversation to make sure you understand what their concerns are before doing the exams.
Katherine Banwell:
Are there resources or programs available for women who don’t have easy access to regular screenings or specialists?
Dr. Heidi Gray:
Yeah, so, one of the really important tools that was developed was the concept of self-screening with HPV. So, as I talked about before, HPV is the virus that causes cervix cancer. And we know, when women have HPV that’s kind of still lingering around in the cervix or the vagina, they’re at higher risk of developing either precancer of the cervix or cancer. Historically, patients had to kind of come in, have a pelvic exam to do the swabs and all of that to test for the Pap test and the HPV – which, again, for many patients, can be a barrier.
Subsequently, what has been developed is the concept of self-collection of HPV swabs. And this was actually approved by the FDA in 2024, in which patients can use – it’s just like a little Q-tip, basically – and collect their own – do a self-collection in the vagina, and send it off to a lab, and it screens for HPV. And it’s incredibly accurate in detecting – meaning that if the HPV isn’t there, the test will come back negative, and that’s a really reassuring thing for a patient. If it does come back positive, it also means that that patient is at risk of developing a precancer or a cancer, and that then is the point where they should engage with the medical community for additional testing.
Katherine Banwell:
What are some common myths and misunderstandings about gynecological cancers that maybe you could clear up for us?
Dr. Heidi Gray:
Yeah, I think just the name sometimes people, like, grapple around. So, I think for a lot of cancers, they’re very solo – like breast cancer, lung cancer, gynecologic cancers.
We have this incredible spectrum of cancers that we manage, and they’re all a little different and unique in their presentation, and their risk factors, and things like that. So, I think that sometimes it’s hard for patients to kind of know what we are treating or how to engage with us. I think that, again, for a lot of patients, also, there can be a lot of fear and anxiety about the worry about losing some of their gynecologic organs if they need to have a surgery or a treatment – the uterus, the tubes, and ovaries – which, to have surgical intervention or other interventions that affect those organs, can be very, very huge barrier and have a lot of concerns for patients about that, so.
Katherine Banwell:
Dr. Gray, as we close out our program, are you hopeful about the advances in screening and diagnosis, and detection?
Dr. Heidi Gray:
I think that we’re really entering an age where our technology and our advances in science – particularly around some of these blood-based screening programs – is really going to hopefully revolutionize how we know who’s at risk of either developing a precancer or a low-level cancer, so we can intervene earlier – either for detecting something that’s precancerous or an early cancer. And that will greatly improve the lives of patients who are facing cancer.
Katherine Banwell:
Well, that’s a promising outlook to leave our audience with, Dr. Gray. Thank you so much for joining us today.
Dr. Heidi Gray:
Thank you very much. Thanks for having me.
Katherine Banwell:
And thank you to all of our collaborators.
If you would like to watch this webinar again, there will be a replay available soon – you’ll receive an email when it’s ready. And don’t forget to take the survey immediately following this webinar. It will help us as we plan future programs. To learn more about gynecologic cancers and access tools to help you become a proactive patient, visit powerfulpatients.org. I’m Katherine Banwell, thanks for joining us.