Experience of Sri Lanka

Courtesy of FIGO

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Dr. Kanishka Karunaratne:  “Thank you very much.  Now my own contribution for this session will be to give an introduction about my experience in the management of gynecological cancers in Sri Lanka.  I’m Dr. Karunaratne, I’m based in the National Cancer Institute in Colombo, Sri Lanka, and I’ll be talking about my experience in the management of gynecological cancers back in my country.  Now just to give a brief introduction about Sri Lanka, what you see in the light green is Amblalantota, Sri Lanka, which is located in the Indian Ocean, is very close in proximity to the southern part of India.  You can see there are four cancer institutions in my country; one is based in the capital, Colombo, and the place where I’m working, one is in the southern part of the country, and two are in the center.  Apart from the Colombo Institution, the other three have limited facilities for the treatment of gynecological cancers.  The total population of Sri Lanka is about 18 million and half of which is females.  There are about ten medical oncologists who deal with chemotherapy and radiation, one gynecological oncological surgeon, that’s me, and there are four surgical oncologist colleagues.  They have good back-up facilities with regard to pathology and radiation as well and also the type of referrals that are done from the teaching hospital where the patients are diagnosed either clinically or histologically and directly referred to my institution or the other three institutions for adjunct treatment.  

What are the problems that we face in Sri Lanka?  Of course, I’m a gynecological surgeon so my talk will be a little biased towards management of gynecological cancer, the surgical aspects.  I was trained in the United Kingdom but when I went back to my country the feeling I had was as if I was swimming in a small stream and suddenly there’s a big storm and I fell into a big ocean.  This is the problem we have because the majority of the cancers we do see in our country are presented late especially with regard to cervical cancers.  Therefore, the treatment is not straightforward; it’s very complicated sometimes and, of course, if the cancers are presented in their late stages, then you’re faced with the problem of recurrences as well.  So this is the incidence of cancer because it’s not very focused but you can see, as was mentioned by two other speakers, the most problematic cancer is the cervix.  About 18%-19% of all gynecological cancers consist of cervical cancer, and being a gynecological surgeon, just to give a rough estimate of the problem in my country, I do see at least two new cases a day in my institution.  Two new cases a day and they’re mostly in advanced stages - stage III or above.  So what is my duty - to evaluate these patients by history and physical information, stage the patients, send them to the proper department for proper regiment treatment, or I’ll either select surgery or refer for radiation or chemotherapy to the proper department.  Then comes the carcinoma morbidity; if you look at the statistics, about ten years ago in my country, carcinoma morbidity is slightly and gradually increasing in number, the incidence was half of this number about ten years ago.  Now it’s about 12% of all female cancers, about ten years ago it was about 6%, carcinoma of the endometrium is about 5%, again, I think it is a little underestimated because a lot of generalists in general gynecology and obstetrics do surgery for carcinoma of the endometrium so we don’t get the proper statistics.  

Carcinoma of the vulva and vagina is about 1%-2%, and we do see a little percentage of malignant gestational trophoblastic disease as well and it’s about .5%-1%.  On my side of the screen you can see a patient diagnosed with advanced stage of carcinoma blastocyst with skin subcutaneous metastasis that she presented.  These are rare problems but we do see a variety of problems but this portion a percent of it from vaginal discharge, of course, due to advanced stage cancer and there are skin deposits all over the body including the scalp.  Then when we biopsied the skin deposits, it proved to be metastatic disease of squamous cell cancer.  Here’s another problem, sadly, this patient again presented with advanced stage of carcinoma of the cervix with bone metastasis and iliac bone articulations.  This part of the leg was swollen, and you can see the metastatic deposit eroded the bones in the foot and the biopsy confirmed it’s a deposit from the squamous cell cancer.  So going back to carcinoma of the cervix, again, it is common between the ages of 45-65 in my country.  Basically, the majority of the patients are post-menopausal.  

One of the field epidemiological studies showed that it is common in females who start their sexual life fairly early in their life.  One study showed clearly that of these patients, about 60% got married before they reached the age of 20.  Again, we looked into the HP virus infection incidence in one study and HPV infection in this biopsy specimen showed that we could prove that 80% of the biopsy specimens that are carcinoma of the cervix include HP virus infection so it’s the same risk factors, which exist globally which we see in our country as well.  As I told you, the majority of the cancers that I diagnose are in advanced stages - stage III or IV in about 80% of the cases.  If you see early presentation like stage I and II that’s in 20%.  The common histological type we do see is cervix cancer in about 95% of people and adenocarcinoma counts as about 5%.  Management – obviously, the majority will have to report to the radiology department for further treatment, and with regard to radiation, we use cobalt radiotherapy machines, we don’t have access to linear accelerators.  We use cobalt machines and what we do is hold pelvic radiation up to 5,000 centigrades in 5/8, and with intracavity radiation, we use micro-electrons and we give a larger dose of intracavity radiation in two insertions, generally, it’s given in four insertions but because of the patient load we give in it two insertions.  I have to work with a very busy radiotherapy department because it’s the radiotherapy department that tackles not only gynecological cancers but other cancers as well.  So the radiotherapy department is overloaded and there are problems, we have to collaborate and work with department.  I try and do surgery in most of the cases that are stage I, stage II-A, and also stage II-B and depending on the lymph node status and involvement of the perimetrium, I only send those in for radiation.  The reason, as I told you earlier, is because head and neck cancers are very common in our part of the world so the majority of the head and neck cancers invariably need radiation so the radiotherapy department are very busy tackling these problems.  

Some challenges we face - chemotherapy as well as chemoradiation especially in the younger patient with bulky disease, and we do use chemotherapy in recurrent diseases.  The agents we generally use are cisplatin, bleomycin, and methotrexate.  This is the changing pattern of the treatment and survival data of the last two decades in my country with regard to cervical cancer.  You can see from 1980-1983 we have been using radio insertion, and we’ve been using the Manchester technique, and you can see the survival figures have been appalling, about 27% in five-year survival.  The central recurrences are about 53%, fairly high numbers, and complication rates with proctitis was about 20% and fairly high.  From 1983 to date they’ve been using remote control loading system as intracavity radiation, and since then, we have been able to achieve good survival figures of five years of going up to about 50%.  You can see the same for recurrences are coming down to about 30%, and most importantly is the complication rate, the proctitis is about 5% so this is what we have been using within the last two decades and improvement with regard to radiation in my country.  

Coming back to carcinoma of the ovary, it’s always a challenge to the gynecologist to treat these patients especially the gynecological surgeon because the majority of disease is presenting in late stages, and the gynecological surgeon has to exhibit his maximum operative skills to deal with these problems.  The most common type of carcinoma that we see in our country is the epithelial type, about 85%, and the median age at diagnosis is about 49 years.  Then the germ cell tumors are about 10%, and you can see they’re presented in fairly early years, about 19 years is the mean age of diagnosis, and the rest of the cancers are fairly rare.  Of course, most of these patients when they are referred to me have optimal surgery, and optimal surgery is pelvic clearance with total abdominal hysterectomy and removal of the tumor masses with extraperitoneal or extrafascial sections, and omentectomy plus or minus any other organs which need to be removed.  As a surgical technique, of course, the numbers of patients with regard to ovarian cancer, which have been referred to me, are mainly for secondary surgery.  This is because the majority of the ovarian cancers in my country are tackled by the generalist so some of these patients have suboptimal surgery and mostly are under treated.  So when I see these patients, they are referred to me by the medical oncologist for a second surgery.  

To give you one example, I have done over 500-600 cases of second surgery compared to maybe about 100 cases of primary surgery so most of my time I deal with the management of recurrences plus the palliation.  It’s not the ideal way of managing ovarian cancers; therefore, results are not very satisfactory compared to other developed countries.  With regard to surgery, my personal feeling is that if you do a good pelvic clearance then you can improve the chances and what I do is if the most problematic area in the pelvis, which is difficult to tackle is the huge deposit in the pouch of Douglas, I go for a rectosigmoidectomy straight away.  If I feel that the deposit in the pouch of Douglas is difficult to remove, I go for a rectosigmoidectomy and clear the pelvis well before doing the upper abdominal part.  With regard to chemotherapy, of course, we are doing well with the chemotherapy because we use platinum with chemotherapy and most of the money has been drained for chemotherapeutic agents in our institution for platinum based chemotherapy.  It’s the first line of chemotherapy, we use either high dose chemotherapy, cisplatin for six courses because we have started using carboplatin as well and the second line cisplatin cyclophosphamide or another combination cisplatin-cyclophosphamide-Taxol but we do use sometimes a second line Taxol as well as taxotin because this is not a very, very wealthy hospital but if you want to get treatment in a private hospital then you might get the benefit of using Taxol.  

Germ cell tumor management is fairly conservative, then again, these modularly tumors are being tackled surgically by the generalist so the chemotherapeutic agent that we use for germ cell tumors is a combination with cisplatin and etoposide and bleomycin of four courses.  Changes in the management and survival with regard to carcinoma of the ovary in the last two decades - you can see from 1980-1990 we have been using adjunct radiotherapy after surgery and survival for stage IV is about 4% of 5 years survival.  From 1990 to today we have been using chemotherapy following surgery.  You can see the survival rate has definitely improved but not alarmingly because, as I told you earlier, the majority of the cancers have been treated by the generalist and the majority are under treated but after we started using chemotherapy, of course, we have an initial good response rate of 60%.  

Coming back to carcinoma of endometrium - statistics have revealed that the incidence is about 3%-5% of all female cancer but as I told you, the majority are tackled by the generalist so we don’t have proper statistics with that and the median presentation is about 51 years.  As I told you earlier, I have to collaborate with the very busy radiotherapy center, and they are full with all stages.  With the ones that are high risk for a bad prognostic factor, I go for pelvic node dissection and even in early stage I, depending on prognostic factors, I cut the specimens in the theater and if it indicates that it infiltrated the myometrium a fair amount, I go for pelvic node and lower periaortic node dissection straight away.  By this method I can differentiate a group, which need radiation, and another group, which doesn’t need radiation so that the people who need radiation are being sent for therapy as adjunct treatment, and the five-year cervical figures are not available because the majority have died.  I’ve done 53 cases in the last four years in my country because the majority are done by the generalist gynecologists.  

With regard to vulval and vaginal cancers, I listened to a nice talk given by John Shepherd from London this morning and previously about reconstructive surgery in gynecological cancer, and it was a very interesting talk.  The problem with the vulval cancers is they are presented in advanced stages, 70% of the patients present in stage III or above.  At my institution, I tackle about 30-35 patients referred annually to me, and you can see this is the type of cancers I get for surgery and some times you see huge granular involvement with palpable nodes.  Some of these nodes are fungating most of the time, and if you want to do primary surgery in these patients, of course you can, you have to have some sort of reconstructive surgery where you use rotate flaps to cover the raw areas.  Most of these cases at the end of the surgery would look like that because you need to get  subcutaneous flap from the abdominal or from the lateral part of the thigh or rotational flap to cover the areas like this.  So surgery being the main mode of treatment in the treatment of vulval cancers sometimes is very difficult, and in some cases I had to call for the assistance of the surgeons as well to cover up these areas.  Management is individualized, again, radical vulvectomy or radical local excision or unilateral bilateral groin node dissection or radiotherapy then referred for radiation for lymph node positive cases and when these cancers present at these stages, the next problem is a recurring disease, and I’ll speak to you about that later on.  

This is a specimen; you can see the lower part of the anus and the rectum being removed and the involvement of the rectum with regard to vulvar cancer.  Malignant gestational trophoblastic disease incidence is about .5%-1% and varying highly deformed nodes are newly diagnosed by the general obstetrician-gynecologist and they’re followed-up by them.  We don’t have a proper system of notification or referral and with regard to malignant trophoblastic disease, my involvement is very much less but I do sometimes get called for management of complications.  Most of the time I’ve been called to tackle cases of interrupt peritoneal bleeding with perforated uterus.  You can see when you open up a patient like that what you see is the perforated uterus with tumor tissues coming out through the myometrium, and you see these tiny deposits scattered in the pelvis.  Even with a touch it is very hemorrhagic so what I do is I just don’t mettle too much.  I don’t mop the areas excessively, and I just tie the internal iliac artery, do a bilateral internal iliac ligation, and then come out.  With chemotherapy most of these patients recover without any problems and some of the cases are referred to me with vaginal bleeding with the deposits in the vagina, so this is another big problem to tackle.  Of course, the only thing I can offer at the time is to pack the vagina tightly and then ask to give them chemotherapy.  Sometimes bleeding continues as strictures for a long time 3-4 days until they get a clinical admissions with chemotherapy so I need to take them to the theater and repack again, then take them the next day and repack again so my involvement with gestational trophoblastic disease is mainly to tackle problems when the oncologist finds trouble.  Then the salvage treatment - as I said, because the majority of the cancers are presented in late stages, you do see lots and lots of recurrences.  With regard to cervical cancer being the most common cancer, I do see a fair amount of central recurrences as well.  

This is a patient with enteric exenteration with the ileum conduit and the problem with this, you know you need to counsel this patient, maybe several days before you get the consent for surgery.  Some of these surgeries are very traumatic and most of the time, we don’t have supplies for stromal care like the conduit bags because the government assistance can’t buy conduit bags unless we have a private fund for that.  So a number of patients are done with the cervix with exenteration about two and the total exenterations about four and you can see there are indications especially the vaginal and three cases of vaginal, vulva, and endometrium as well.  What I do when I don’t have these stroma bags is I put a Foley catheter in.  The problem of putting a Foley catheter in is it can get blocked because the low mucous being secreted by these conduits but that can be overcome by asking the patient to drink excessive amounts of water and make the urine very watery.  But I have with greater difficulty opened a fund to help these people who are undergoing these operations.  I feel it’s not fair for the patient if I don’t have good health facilities to offer them for post-operative care.  

So is there a way for us to improve the gynecological cancers for Sri Lanka?  Are we going backwards or are we going forward or are we going to stay in the same place?  First of all, I think a cancer notification system is a priority in my country; most of the gynecological cancers treated in the country are not notified to a central case.  During these four years I have shouted so much, I’m a lonely fighter in my country but still I have shouted so much that now I have adopted a policy to notify all gynecological cancers in my country which we launched a few months ago.  I’m sure we can have a good notification system as time goes on, maybe in about another three or four years time.  Then recognition that gynecological oncology is a subspecialty.  I have told this over and over again and recently our oncology obstetrician gynecologists were recognized and gynecology oncology as a subspecialty.  We are hoping to train in the future a few more gynecological surgeons.  

This is a lady on this side of the screen, she was 84 years old and that was about three years ago.  She was diagnosed as stage II carcinoma of the cervix, and I did a radical hysterectomy for her.  That was three years ago and now she is doing perfectly well.  Now with regard to screening - of course, is to tackle the most problematic area of cervical cancer with regard to screening, at least the population at risk.  What I feel is in the whole world about ½ million of female patients are suffering from cervical cancer annually.  Out of that, two-thirds live in the developing world, that is about 300,000 - 400,000 people are living in the developing world.  Out of that, over 50% die annually, that means we lose about 200,000-250,000 females annually in the developing world due to cervical cancer.  I’m sure if you compare that with the number of deaths from HIV it is more or less the same, I’m sure.  

So what are we going to do for these patients?  First of all, to initiate a screening program in a country, you have to prove to the government that this is a health problem.  I have been trying to do this for the last three years but I have succeeded recently and now the concept of a women’s clinic, which have existed in the developed world for such a long time, I’ve been able to introduce to my country as well with the help of some of the non-government organizations.  By raising fair amount of funds, we have established 300 such clinics in various parts of the country.  The function of these clinics is not to do a Pap smear alone but to give a general service for the females like checking their hemoglobulin for anemia, treating anemia, checking urine for urine sugars, screening for diabetes, checking for malnutrition, and at the same time of course doing a Pap smear.  We are at the moment targeting five districts in my country with regard to screening of gynecological cervical cancers.  I’m sure this is going to be a long process, and we can learn so many lessons from the developed countries especially from the United Kingdom.  They initiated a cervical cancer screening program in the 1960’s until mid-1980’s, it didn’t target proper results because of sudden deficiencies so we can learn so many lessons from the developed countries, and with those lessons we can march forward.  I’m sure, provided you insist the government recognize that this is a health risk problem for your females in the country.  This patient is the mother of one of my friends, that’s the reason that she came early and was operated on.  She was 84 years old three years ago and she’s doing very well.  

Thank you very much.”