You can go ahead and start. Can I get started? Yes, go right ahead. Okay. Good morning, everyone. My name is Chie Nagata from the Jukei University School of Medicine, which is located in Tokyo. Today, Dr. Kao, you kindly invited me to give a lecture here, and it's a great pleasure for me. So I'll be talking about healthcare for gynecologic cancer survivors today. Okay. Just let me turn off my, my video. Okay, good. So, um, so my name is Chie Nagata. So before starting my talk, I would like to introduce myself briefly. My name is Chie Nagata from Japan. I'm an assistant professor at the Department of Obstetrics and Gynecology at the Jukei University School of Medicine, and I'm also a joint research fellow at the Department of Health Policy at the National Center for Child Health and Development. So, I'm board certified obstetrician gynecologist, but basically I am a specialist of epidemiology and public health, and my clinical interest is women's healthcare in general, menopausal disorders, genitourinary symptoms of menopause, PMS, PMDD, well-being cancer survivors, and healthcare for adolescents. So this is a picture of my university, the Jukei University School of Medicine, which is a private medical school with four university hospitals with 2,671 beds in total, and located in Tokyo metropolitan area and founded in 1881. A few countries gave us a lecture last year, and that was fantastic, and we met there. Okay, so, okay, so this is just starting, just before starting my talk, I would like to briefly introduce the health systems in Japan, because I believe it's quite different across countries. So, Japan adopts universal health coverage, so basically all Japanese are covered by health insurance, most of the medical practices conducted under the health insurance system, and also people have free access to hospitals, so they can go directly to the hospitals of their choice. And the maximum co-payment is up to 30% of the medical expenses, and depending upon their income, and the people will be subsidized about a certain amount of co-payment if it is too expensive, so usually like the maximum amount of payment out-of-pocket payment would be around 700 US dollars or something per month. So, the regulatory approval system in Japan is quite rigorous, and it's really closely linked with the health insurance coverage, so we usually use the drugs and medical devices, which has been approved and covered by health insurance, so we really can't use any devices or any drug, unless they are approved. So, today's topic is healthcare for gynecology cancer survivors. So, why is it important? So in Japan, cancer survivors are increasing, and now it's estimated to be 3.4 million, and out of the population of 125 million, I think the situation is similar to China as well. So, specific to cervical cancer in Japan, we have like 10,000 new cases every year, and three in four patients will be a cancer survivor, and for uterine cancer, we got 70,000 new cases per year, and four in five of them will be a cancer survivor. And for ovarian cancer, we got 13,000, and those are two in three of them will be a cancer survivor. So, there is a piling up number of cancer survivors in this country. All right. So, as you all know, gynecology cancer survivor has their really specific issues. Cancer and its complications themselves are a really big issue for them, of course, and they do have like psychological impact and social and economic impact. These are big issues too. In addition to them, patients have adverse effects from treatments like lymphedema, urinary dysfunction, surgical menopause, and so on. So, these are the top down health-related issues among gynecology cancer survivors reported by Western et al. This study was conducted in US, and the top issue reported by patients was fatigue, followed by sexual dysfunction, sleep disturbance, and neurologic symptoms. And also, these issues are heavily impacted by what treatment they received. So, compared to surgery only, like combination treatments such as surgery plus chemotherapy, surgery plus radiation, and three of them have like increased risk of health-related issues reported by cancer survivors. Okay. So, there is a large number of issues we have to deal with, but in today's session, I would like to talk about the surgical menopause, which really has huge impact on other symptoms as well. All right. So, as you all know here, natural menopause could cause multiple symptoms. In the short term, there are multiple symptoms, fatigue, depression, and gender urinary symptoms, and sexual dysfunction are very typical symptoms for women with natural menopause. And in the long term, menopause impacts women like lipidemia, blood pressure, cardiovascular disease, and stroke, and osteoporosis, and memory problems. And if that woman has surgical menopause, what's the difference compared to natural menopause? So, it is reported that surgical menopause is related to abrupt withdrawal of estrogen, progesterone, and androgen, which causes more severe and prolonged menopausal symptoms and increased risk of adverse mood, heart disease, excessive bone resorption, sexual dysfunction, and cognitive disorders. All right. So, this study is quite famous and interesting. This is reported by GERAC et al. And so, this is about the relationship between the age-up bilateral self-endophrectomy, BSL conducted, and this patient's mortality. So, this BSL was conducted for benign gynecologic diseases, not cancer. So, even though those patients had benign diseases, still, BSL causes an increased risk of mortality. And this relationship is attenuated with age. So, the patient is younger, the mortality risk increases larger. Okay. So, what can we do for this situation? And there's always non-hormonal treatment, but hormone replacement therapy is also a very strong method to treat this situation. So, in this session, I would like to focus on hormone replacement therapy, which is abbreviated HRT. Okay. So, I think all of you here know that there is certain contraindications for HRT. In general, HRT is contraindicated in women with, like, unexplained vascular bleeding, liver diseases, prior estrogen-sensitive cancers, primarily coronary heart disease, stroke, myocardial infarction. So, myocardial infarction and venous thromboembolism, and a personal history of inherited high risk of thromboembolic diseases. Okay. So, what about the HRT specific to cancer survivors? So, for example, cervical cancer survivors. So, it's been reported that no evidence has reported a harmful effect of HRT on CC on cervical cancer oncological outcome. So, some cervical cancer survivors would be good for HRT in many cases, but we have to be really careful about the adenocarcinoma because a very weak increase in the incidence of adenocarcinoma has been shown among women treated with HRT. So, what about the endometrial cancer survivors? Generally, HRT is contraindicated in women with estrogen-responsive cancers. And, however, HRT may be used to treat menopausal symptoms in women with low-grade stage 1 endometrial cancer after hysterectomy. However, HRT is not advised with high-grade advanced stage endometrial cancers and endometrial stromal sarcomas or leiomyomyomyosarcomas, and there is really insufficient studies assessing the safety for those patients. And, yeah, basically, the Cochrane review is also concluded in the same way for endometrial cancer survivors. Okay, so what about ovarian cancer survivors? HRT does not appear to affect recurrence risk or survival, although most of these are observational studies and there are only two RCTs for this research question. However, these two RCTs are concluded in the same way. So, basically, ovarian cancer survivors also could be a candidate for HRT after the surgical menopause. But HRT is not advised in women with hormone-dependent ovarian cancer, such as granulosa tumors and serous carcinomas. So, the upper paper is a systematic review which included observational studies as well as RCTs, and this type of systematic reviews are more positive about the HRT for ovarian cancer survivors. And the bottom paper is Cochrane review, and Cochrane review still has the same kind of conclusion about the HRT for ovarian cancer patients. And what about the BRCA mutation carriers after risk-reducing BSO? Most of the guidelines and papers, systematic reviews, support HRT use for those patients with BRCA mutation carriers after risk-reducing BSO. Okay, however, what about the clinical uptake for this? Even though we have certain levels of evidence for HRT for those patients, so, for example, the top paper, the above paper is from the U.S., and it says that HRT was prescribed to less than half of the patients with newly diagnosed cervical cancer patients under the age of 50. So, uptake of the HRT for cancer survivors is not really prevalent. And also, the bottom paper is from Italy, and it says that Italian gynecologists are not so positive about prescribing HRT for cancer survivors. Okay, so then who should take care of gynecologic cancer survivors, especially who had premature menopause? Okay, so this is just my image of gynecologic oncologists like saving people's lives and like a hero. But this is my image of women's healthcare professionals walking or running with patients in a long distance, in a long period. So, maybe we can be a very good partners. So, in the treatment period, so many number of specialists are involved to treat the patients. But after that, like during follow-up period, usually like gynecologic oncologists are the main doctor who take care of the patient, checking recurrence, treating adverse effects by treatment. But women's healthcare professionals, such as gynecologists, can be a good partner with them. We can do like provide HRT or non-hormonal therapy for them, and then we can check bone density, serum levels, and blood sugar, and blood pressure, and breast cancer screening, and treat sexual dysfunction, etc. Then, after that patient completely cured down the leaf from follow-up, they can go to the, like we do have really like comprehensive medical checkup in Japan, like which is called an Indian doc, and they can receive like general check, general health, and also to check general cancer, secondary cancer, other than the gynecologic cancer. And maybe like family, their family doctors can help them as well. Okay. So, thank you very much for listening. And please, please feel free to email me, because I have outpatient clinic this morning, and I have to excuse shortly. So, should you have any questions, please feel free to email me to this email address. And I'm very happy to have a collaborative research, such as comparative study in clinical practice, or patient's perspective, attitude, and behaviors. These are my specialty. And also, I'm really interested in clinical trials for women's healthcare, and also epidemiological studies, cohort studies, and insurance claim data analysis, and so on. It was a great pleasure for me to give a lecture here, and thank you very much for listening.

gynecologic cancer survivors

universal health coverage

surgical menopause

hormone replacement therapy

specialized care