Sabrina Serani 0:07 This is Targeted Talks. I'm Sabrina Serani. Gynecologic cancers don't always get the spotlight, but for the clinicians treating them, the questions are constant. Which patients benefit from the newest therapies? How do you translate the latest data and trivial decisions at the bedside, and what does the research actually mean for day-to-day care? In honor of September as Gynecologic Cancer Awareness Month, we are digging into those questions with someone who treats these patients every day. My Noelle Gillette Cloven, MD 0:33 name is Noelle Gillette Cloven. I'm a gynecologic oncologist at Texas Oncology at the Fort Worth Cancer Center, and I'm also the executive chair for the GYN Research Committee for Sarah Cannon Research Institute. Sabrina Serani 0:45 For our listeners who are not seeing patients with gynecologic cancers on a daily basis, can you give some context into how these patients are presenting by the time that they arrive in your clinic? Noelle Gillette Cloven, MD 1:00 As a gyo and oncologist, I'll usually see patients who've already been diagnosed. Okay, and and it does differ by cancer type. So, for example, most women with endometrial cancer they present with abnormal bleeding, usually postmenopausal, but not always, and they've had a biopsy done by a gynecologist, and they're referred to us with the diagnosis, now ovarian cancer is a little bit different. That those ladies, you know, may come in with a CT scan that's suspicious. You know, maybe there's a mass on the ovary. There could be ascites. It could have some symptoms, but they don't have a diagnosis when they see me. For cervical and vulvar cancer, it's mixed, but most of the time, those patients have already been diagnosed with cancer by a biopsy done by either the primary care physician or a gynecologist. Sabrina Serani 1:48 We have seen the incidence and the prevalence of gynecologic cancers rise, fall, shift over the past several years. Could you give us a snapshot of what these incidence and prevalence rates are looking like today. Noelle Gillette Cloven, MD 2:05 Yeah, so that's an excellent question. The good news is for ovarian cancer, the incidence seems to be decreasing. So we're possibly because we're doing better at genetic testing and then doing risk-reducing surgery. Maybe we're recognizing women who are at risk so they can take action to prevent getting ovarian cancer. While the prevalence of ovarian cancer is still on the rise, so what that means is that there's more women today living with ovarian cancer, and that's just because our treatments have improved. So the incidence, the number of people diagnosed, is decreasing, but the number of people alive with ovarian cancer is increasing because women will often live for a very long time on treatment. With cervical cancer, the incidence is decreasing. Thankfully, we have both a screening test, which is the Pap test, combined with HPV testing and a vaccine for cervical cancer. So the incidence of cervical cancer continues to decrease, although it's not zero. There are still women who are screened and have have been vaccinated that can get cervical cancer. So it's not been eliminated yet for endometrial cancer. That is the one gynecologic cancer that is increasing. We're seeing an increasing incidence of that cancer, particularly some of the high risk subtypes. So there's different types of endometrial cancer, but some of the ones that often have a higher stage and are more aggressive, we're seeing those types increase. And it's also particularly more prevalent in African American women. So, and we're not really sure why, but it's just something to be aware of. Sabrina Serani 3:38 So, let's get a little bit more technical for a moment, could you explain BRCA and HRD testing to a colleague who is not in your field, and why those are so important, particularly for ovarian cancer? Noelle Gillette Cloven, MD 3:57 Okay, so sometimes it can be very difficult to explain, so there is genetic testing. It can be a blood test or cheek swab, where we're testing a patient's actual DNA to look for mutations. Okay, and those mutations are in every cell in their body. They can be passed down to other family members. So that's important to distinguish from HRD testing. HRD testing as somatic testing, so that's where we test the tumor. So, and we do both in ovarian cancer. So we'll test for genetic mutations which occur in about 20% of ovarian cancer. That's important to detect those because it could indicate that the patient's at a higher risk of other cancers, and other family members might also be at risk. But the somatic testing, so where we test the tumor, one of the most important things that we test for is HRD testing, and that stands for homologous recombination deficiency. And so, we know that these tumors don't respond as well to PARP inhibitor maintenance. It doesn't change anything really in the initial treatment, but once the. Patients are they've completed their chemotherapy and hopefully are moving into the maintenance phase. This will determine what sort of maintenance, if any, that we give the patient, whether the HRD positive or negative, and that is a test of the tumor, not necessarily of the DNA. Sabrina Serani 5:15 And for these tests, when during the course of a patient's cancer journey, are they receiving these tests? Are they being tested multiple times? What is the testing timeline looking like? The Noelle Gillette Cloven, MD 5:30 somatic testing, so the tumor testing, is usually done. Nowadays, we're doing a lot of what's called neoadjuvant chemotherapy. So rather than going straight to surgery, ovarian cancer is very chemo sensitive, so a lot of times we'll use chemotherapy to shrink the tumors, and that way the surgery doesn't have to be so radical. So the patients are tested; they they have a biopsy to get the diagnosis, and it's very important that a biopsy is done. That it's a core biopsy, not an you don't want an FNA because we need to have an actual tissue diagnosis for a couple of reasons. One is to get the HRD testing because that's going to help us determine what sort of maintenance. But also, sometimes it's not ovarian cancer, you know. And in addition to that, there's different types of ovarian cancer. We have both high grade and low grade serous ovarian cancer, and the treatments are extremely different for those. So the biopsy is usually done. Sometimes it's done before patients are sent to us. Sometimes they come to us and we order the biopsy. But the genetic testing, we often refer them for that to a genetic counselor sometime during their initial six cycles of therapy. We don't normally repeat the genetic testing unless it's been a very long time and new data. Some patients were tested 15 years ago, and we weren't testing for as many genes. So we might run a retest at that point, but but typically not. Sabrina Serani 6:48 All right, let's switch gears to cervical cancer for a moment. The screening guidelines have been in flux for many years. Could you give us a snapshot of what the status of screening guidelines are in cervical cancer today? Noelle Gillette Cloven, MD 7:05 I think that the screening guidelines have really confused everybody. To be honest, you know they they're constantly changing. It was, in my opinion, it was much easier when everyone just had a Pap spill once a year. You went in for your annual because you know, and I understand the reasoning for extending the interval to to three years if you have a normal Pap and a HPV test. But at the same time, that makes it more difficult for patients to remember when they're due for their Pap test. So I think it just it adds that other degree of complexity. The other thing that that that I really disagree with is the guideline that states that after 65, you no longer need a Pap test because over a third of women with cervical cancer are diagnosed after 65, and you know people live longer nowadays. So I I personally feel that if a woman is healthy and vigorous and you know, there's just really no reason to stop doing pap tests at a certain age. I think that they should still be screened. Sabrina Serani 8:08 I will say, from a patient perspective, the number of times that I have been standing at a receptionist desk at a doctor's office, and they have asked me how long ago was your last pap, and I am trying to do mental math, calculate. It's it's so overwhelming from a patient perspective. I wish it were every year, just so I don't have to keep track. Noelle Gillette Cloven, MD 8:34 I know it's so hard, and then then it gets then it just gets lost, and you know I don't know it makes it difficult. Sabrina Serani 8:40 On to endometrial cancer. Is there a symptom that often gets overlooked by clinicians? Noelle Gillette Cloven, MD 8:52 I guess the one thing I would say. So typically, like I said, most of the time, women, you know, fortunately, are postmenopausal when they're diagnosed, and anytime anyone has postmenopausal bleeding, that's usually not something that's dismissed. So, so those ladies get a fairly prompt diagnosis, and the cancer is usually detected in early stage and very treatable. What I would say is, in the younger women, I think they're often irregular bleeding. In a younger woman, particularly, there's you know obesity is a big risk factor. PCOS is a big risk factor. So I think sometimes you know it's easy to, you know, in someone that's premenopausal or younger than 40 to you kind of say this is just related to, you know, hormones or PCOS, and maybe treat with birth control pills and not get a biopsy. So that that would be the one thing I would say is I have seen some delay in diagnosis in younger people, which is really justified because it's not that common. But I think it just means that you need to be, you know, stay aware that that could be keep that in the differential diagnosis, especially in somebody that it's it's continues on and and has risk factors. Sabrina Serani 9:57 All right, let's talk myth bust. For a minute, are there any myths in gynecologic cancers, whether it's ones that patients have or clinicians have, that you would like to dispel? Noelle Gillette Cloven, MD 10:10 One thing is that a lot of people think if they have a Pap smear, that screens for all gynecologic cancers. This is something for patients mainly, and you know, and women come in and you know, with ovarian cancer, unfortunately, sometimes it comes out of nowhere. You know, and these are women that take care of themselves, and they're healthy, and they exercise. They don't have a lot of health issues, and and they're getting their regular GYN exams. And next thing you know, they've got stage three ovarian cancer, and they say, "Well, I just had my Pap test. It's not screening for that. The Pap test is designed to screen for cervical cancer. You know, I think that is something I'd like to dispel. The other thing is, like we talked about with the guidelines changing every time you go in for your well woman exam, a lot of patients don't know that they're not getting a Pap test. You know, they have the pelvic exam part, but you got to separate that from the from the Pap test. I guess I'd also say that there's a lot of myths regarding clinical trials. Patients and physicians alike will think that well, you know, that's the last resort. You know, you should go. You once you've exhausted all, you know, standard of care treatments, then you look for a clinical trial. I think that that's something that at diagnosis you should look and see what clinical trials are available for you because oftentimes that might might be a way to get access to newer, more state of the art treatments Sabrina Serani 11:27 for any physicians or non-GYN onks who are listening. What is something that you would want them to take away from your experience that they can apply to their practice. I Noelle Gillette Cloven, MD 11:42 think one thing that that that definitely they could apply to their practice would be making sure you get a good family history from the patient. You know, a lot of times you know that can lead to genetic testing, and like I said, that's been one of the things that I believe has been one of the things that has led to decreased incidence of ovarian cancer. So, getting a good family history is important. Also, I've seen, you know, I see this sometimes. You know, patients, for example, maybe an elderly woman that has, you know, itching or you know, vaginal itching or vulvar itching, and they just are prescribed creams, and no one really does an exam. I would say it's always important to to just look down there. You know, I mean, I think nowadays we're so into you know we're all on our computers and you know we're getting CT scans and PET scans, but sometimes just just a good old fashioned physical exam is is really important. And I know not all at least primary care doctors are set up to do a pelvic exam, but that but if if anyone has any sort of persistent symptoms, they should be sent to a gynecologist for an exam. And then one final thing is, I have seen sometimes women that are treated for urinary tract infections over and over again because there's blood in their urine, but it turns out that there was never blood in the urine they're having vaginally, and the patient didn't. You know, it's sometimes hard to tell where it's coming from, and so I think that's another another thing to say. You really need to have a pelvic exam, and and nobody wants a pelvic exam, you know. I mean, none of us do, but it is important. So I'm a big believer in that. Sabrina Serani 13:14 And what is making you hopeful about the field of gynecologic oncology and the progress it's making, and where we are in 2026. Noelle Gillette Cloven, MD 13:24 So I am so hopeful. I'm very passionate about clinical trials. That's one of the things that I'm extremely involved in, and we're starting to see breakthroughs. First of all, with cervical cancer, you know, the decreasing incidence is amazing. But for patients who do develop cervical cancer. We're starting to find ways to integrate immunotherapy into treatment, and we're getting better outcomes. And it used to be when I when I first started my training, if the cervical cancer had metastasized, there was really not a lot you could do. I mean, the the chance of of anything helping was very low, less than 15% and since the late 90s, we've increased the survival for metasexarable cancer by over five times between adding targeted therapies and immunotherapy, and we're still working on new treatments to improve that for ovarian cancer, platinum resistant. So once the ovarian cancer became resistant to chemotherapy. Similar situation. The response rates were very low, maybe 15% We're developing these new drugs called antibody drug conjugates, and the responses are better than I've ever seen before. And not only are they higher responses to treatment, but patients are able to stay on therapy, and and their disease is controlled. I mean, we haven't got to the point where we can necessarily cure it, but I think that's something that we can actually look forward to in the horizon. And then with endometrial cancer, same thing with immunotherapy and certain subsets of patients where we're doing the malady. Profiling and looking for certain mutations, we're heading towards a non-chemo option for advanced and metastatic endometrial cancer, where we're targeting specific you know receptors on an individual person's cancer cells. So it's a pretty exciting time to be in gynecologic oncology. The breakthroughs are happening more and more quickly. We've had, I think, in the past few years we've had 16 new FDA approvals for gynecologic cancer. We're expecting more next year, so it's it's it's going very well, and I'm very hopeful. And I I want all patients to to know that that we're working really hard to try to find new treatments. Sabrina Serani 15:51 Thanks for tuning into this episode of Targeted Talks. Catch us next Tuesday for another conversation in cancer care. Transcribed by https://otter.ai