Expert Discusses Challenges in Gynecologic Cancers

Shitanshu Uppal, MD

Although significant advances are occurring in ovarian cancer, such as the ongoing breakthroughs with PARP inhibitors, other gynecologic cancers remain underfunded and under-researched.

Shitanshu Uppal, MD, says that funding for cervical and endometrial cancer research from the National Institutes of Health (NIH) is almost non-existent, and cases of endometrial cancer have increased steadily over the past 10 years.

“Gynecologic cancer money has just vanished,” says Uppal. “There is no infrastructure to deal with these people and their healthcare issues.”

Lack of funding for these cancers is an important issue to consider, says Uppal, as there is a very clear correlation between obesity and endometrial cancer that should be investigated, but there is no money being allocated toward research.

Much of the small amount of money that is granted to non-ovarian gynecologic cancers goes toward cervical cancer vaccine development; however, many parents choose not to vaccinate their children. Uppal poses the ethical question of whether there should be ramifications for parents who do not vaccinate children who then contract HPV and develop cancer later in life.

In an interview with OncLive, Uppal, assistant professor of obstetrics and gynecology at Michigan Medicine, discusses the critical challenges to research and treatment advances in cervical and endometrial cancer.

OncLive: How has the stigma around the HPV vaccine effected cervical cancer?

Uppal: I think that one of the very fascinating discussions that I've had is that, with most vaccines like the measles vaccine, if a child has that disease it eventually goes away. The thing with the HPV vaccine that is different, if a parent doesn't get a HPV vaccine for a child, when they get older it is not as efficacious. Can a child sue their parents when they grow up? I just recently had this discussion and I don't know, I am going to have to dig deeper. The child turns 18 and says to their parent, “You failed to protect me from several different cancers.” I do not know where the rights of the minor come in here, how does the child come into the discussion of whether or not they should get that vaccine.

The majority of vaccines [are for diseases] that happen to the child when it is a child and then the disease goes away, and they do not have repercussions of that disease when they are an adult. Here, we are talking about the child not getting that vaccine as a child and the repercussions of that happening when they are 26 to 45, when the majority of cervical cancer happens. A parent could presume that their child will never have sexual intercourse with multiple partners, but after 18 it is no longer their control—that is an individual with their own rights.

You cannot talk about cervical cancer without talking about the HPV vaccine and some of the things that are related to it.

What is one of the most pressing challenges in gynecologic cancers?

I and one of my colleagues did a study about how much grant money from the NIH is being allocated toward individual cancers. And we looked at these metrics from several different angles, one way was just the pure prevalence of the cancer—breast cancer is the most common cancer, lung cancer is very common. We then calculated a metric—if 100 women or men get a cancer, how many of them will die? Essentially, how lethal the cancer is. And then we figured out if there is some sort of equitable distribution of grant money. When we make the graphs, we have to take breast cancer off of the charts because the distribution of wealth is very different. These non-ovarian gynecologic cancers—endometrial and cervical—have no money. Whatever money that goes into cervical cancers will be vaccine-related studies, but there is nothing else.

How has this effected treatment for patients?

With this metric of how much money is being spent in these cancers we also looked at how many NCCN guidelines are supported by high-level evidence, and it’s a simple math—the more money put in, the more evidence you have. The incidence of endometrial cancer has gone up in the United States from 40,000 to 60,000 cases in the past 10 years. None of the other cancers are going up like that, which is directly related to obesity, but there is no money for research.

There is no NIH money going to obesity or endometrial cancer survivorship—80% to 90% of patients with endometrial cancer come in and we remove their uterus and that’s it. This is important to keep track of though, because it is a marker of obesity. It is telling us that obesity is so bad that it is causing cancer. What do we do with these patients? We see them for 2 years and then they disappear.