Principles and Practice of Gynecologic Oncology

1. 5.1 Endometrial Cancer: Introduction, Anatomy, Natural History, and Patterns of Spread - p. 122 2. Introduction - p. 123 3. Anatomy - p. 123 4. Classification - p. 124 5. References - p. 125 6. 5.2 Endometrial Cancer: Etiology, Epidemiology, Risk Factors, Genetics, and Molecular Biology - p. 126 7. Epidemiology and Risk Factors - p. 127 8. Natural History of Disease - p. 128 9. References - p. 128 10. 5.3 Endometrial Cancer: Clinical Presentation, Diagnostic Evaluation, and Workup - p. 129 11. Diagnostic Evaluation - p. 130 12. Clinical Presentation - p. 130 13. Diagnostic Workup - p. 131 14. References - p. 132 15. 5.4 Surgery for Endometrial Cancer - p. 133 16. 5.5 Endometrial Cancer: Pathology and Prognostic Factors - p. 148 17. Pathologic Factors of Prognostic Significance - p. 148 18. Pathology - p. 150 19. References - p. 156 20. 5.6 Therapy for Endometrial Cancer: Radiation, Chemotherapy, Targeted, Immunotherapy, and Other New and Novel Agents - p. 159 21. General Management - p. 159 22. Adjuvant Radiation Therapy - p. 160 23. Special Situations - p. 165 24. Radiation Therapy Techniques - p. 165 25. Systemic Therapies - p. 167 26. Angiogenesis - p. 172 27. References - p. 174 28. 5.7 Treatment of Persistent and Recurrent Endometrial Cancer - p. 180 29. 5.8 Endometrial Cancer: Special Conditions - p. 180 30. 5.9 Endometrial Cancer: Follow-Up and Survivorship Issues - p. 182 31. Surveillance - p. 183 32. Survivorship Issues - p. 183 33. References - p. 184 34. 5.10 Endometrial Cancer: Future Directions - p. 185 35. SECTION 6: CORPUS: MESENCHYMAL TUMORS - p. 187 36. 6.1 Mesenchymal Tumors: Introduction, Anatomy, Natural History, and Patterns of Spread - p. 188 37. Introduction - p. 189 38. Anatomy - p. 189 39. Natural History - p. 189 40. Patterns of Spread - p. 190 41. References - p. 190 42. 6.2 Mesenchymal Tumors: Etiology, Epidemiology, and Risk Factors - p. 190 43. Histologic Distribution - p. 191 44. Risk Factors - p. 191 45. References - p. 192 46. 6.3 Mesenchymal Tumors: Clinical Presentation and Diagnostic Evaluation and Workup - p. 193 47. Clinical Presentation - p. 193 48. Diagnostic Evaluation/Workup - p. 194 49. References - p. 196 50. 6.4 Surgery for Newly Diagnosed Uterine Corpus Mesenchymal Tumors - p. 197 51. Surgery for Newly Diagnosed Patients - p. 197 52. Preoperative or Intraoperative Diagnosis - p. 197 53. Postoperative Diagnosis - p. 200 54. References - p. 201 55. 6.5 Pathology of Uterine Mesenchymal Tumors - p. 202 56. Introduction - p. 202 57. Overview of Molecular Landscape of Uterine Mesenchymal Tumors - p. 203 58. Endometrial Stromal Neoplasms - p. 205 59. Stromal Nodule - p. 206 60. Müllerian Adenosarcoma - p. 208 61. Uterine Tumor Resembling Ovarian Sex Cord Tumor - p. 208 62. Perivascular Epithelioid Cell Tumors - p. 209 63. Inflammatory Myofibroblastic Tumor - p. 210 64. References - p. 210 65. 6.6 Radiation Therapy for Uterine Corpus Mesenchymal Tumors - p. 212 66. 6.7 Chemotherapy for Uterine-Limited and Advanced Uterine Sarcomas - p. 215 67. Introduction - p. 216 68. Limited or Completely Resected Disease - p. 216 69. Neoadjuvant Chemotherapy - p. 217 70. Chemotherapy for Metastatic Disease - p. 217 71. Toxicity of Systemic Therapies - p. 223 72. Systemic Therapy: Summary - p. 223 73. Hormonal, Targeted, Immunotherapy, and Other, New, and Novel - p. 223 74. Biologic and Targeted Therapy - p. 224 75. Immunotherapy - p. 226 76. Novel Agents - p. 227 77. Hormonal, Targeted, Immunotherapy, and Other, New, and Novel Therapy: Summary - p. 227 78. References - p. 227 79. 6.8 Surgery for Persistent and Recurrent Uterine Sarcomas - p. 231 80. 6.9 Uterine Sarcomas: Follow-Up, Survivorship Issues, and Future Directions - p. 232 81. Surveillance Recommendations - p. 232 82. Future Directions - p. 233 83. References - p. 233 84. SECTION 7: GESTATIONAL TROPHOBLASTIC DISEASE: MOLAR PREGNANCY AND GESTATIONAL TROPHOBLASTIC NEOPLASIA - p. 235 85. 7.1 Epidemiology, Genetics, and Pathology in Gestational Trophoblastic Disease - p. 236 86. Introduction - p. 237 87. Epidemiology - p. 237 88. Genetics - p. 238 89. Pathology - p. 238 90. References - p. 245 91. 7.2 Management of Molar Pregnancy - p. 246 92. 7.3 Management of Low-Risk Gestational Trophoblastic Neoplasia - p. 251 93. 7.4 Management of High-Risk Gestational Trophoblastic Neoplasia - p. 256 94. 7.5 Gestational Trophoblastic Disease: Postdiagnosis and Treatment, Long-Term Sequelae, and Quality-of-Life Issues - p. 267 95. Introduction - p. 267 96. Future Fertility - p. 267 97. References - p. 269 98. SECTION 8: EPITHELIAL OVARIAN CANCER - p. 271 99. 8.1 Epidemiology and Risk Factors - p. 272 100. 8.2 Hereditary Ovarian Cancer: BRCA and HNPCC—Panel Testing - p. 283 101. Biology of BRCA-Associated Ovarian Cancer - p. 284 102. Clinical Features of BRCA-Associated Ovarian Cancer - p. 285 103. Gene Panel Testing of Germline DNA and Counseling - p. 286 104. Follow-up of BRCA1/2-Positive Patients Who Do Not Want to Undergo Risk-Reducing Salpingo-Oophorectomy - p. 288 105. Prophylactic Risk-Reducing Salpingo-Oophorectomy for Prevention of BRCA-Associated Ovarian Cancer - p. 289 106. Biology and Clinical Features of Lynch Syndrome–Associated Ovarian Cancers - p. 291 107. Prophylactic Surgery for Prevention of Lynch Syndrome–Associated Cancers - p. 292 108. References - p. 293 109. 8.3 Natural History of the Disease: Patterns of Spread - p. 294 110. Mucinous, Clear Cell, and Endometrioid Ovarian Cancer - p. 295 111. Serous Papillary Ovarian Cancer - p. 296 112. Lymph Node Metastasis - p. 297 113. Recurrent Ovarian Cancer - p. 298 114. References - p. 298 115. 8.4 Ovarian Cancer: Etiology, Genetics, and Molecular Biology - p. 299 116. Ovarian Cancer Etiology - p. 300 117. Ovarian Cancer Genetics and Genomics - p. 300 118. High-Grade Serous Ovarian Cancer - p. 302 119. Endometrioid and Clear Cell Ovarian Cancers - p. 306 120. Synchronous Endometrioid Ovarian and Endometrial Cancers - p. 307 121. Borderline and Invasive Low-Grade Serous Ovarian Cancers - p. 307 122. Mucinous Ovarian Cancer - p. 307 123. Future Directions - p. 308 124. References - p. 308 125. 8.5 Ovarian Cancer: Clinical Presentation and Diagnostic Workup - p. 309 126. Clinical Presentation of Patients With A Benign Adnexal Mass or Early-Stage Ovarian Cancer - p. 310 127. Clinical Presentation of Patients With Advanced Ovarian Cancer - p. 310 128. Diagnosis of Ovarian Cancer - p. 316 129. Clinical Examination - p. 317 130. Laboratory Tests - p. 318 131. Imaging of Adnexal Masses and Early Ovarian Cancer: Ultrasound and Magnetic Resonance Imaging - p. 321 132. Imaging of Advanced Ovarian Cancer: Computed Tomography, Positron Emission Tomography Scan, and Magnetic Resonance Imaging - p. 325 133. Differential Diagnosis of Ovarian Cancer - p. 326 134. References - p. 326 135. 8.6 Surgery for Ovarian Cancer - p. 326 136. Introduction and definitions - p. 326 137. Early-Stage Ovarian Cancer - p. 328 138. Advanced Epithelial Ovarian Cancer: Rationale for Surgical Debulking - p. 330 139. Surgical Debulking—Pelvic and Upper Abdominal Procedures - p. 334 140. Role of Lymph Node Dissection in Surgery for Advanced Ovarian Cancer - p. 335 141. Neoadjuvant Chemotherapy - p. 336 142. Hyperthermic Intraperitoneal Chemotherapy - p. 336 143. Summary of Primary Debulking Surgery for Ovarian Cancer - p. 337 144. Interval Debulking for Suboptimally Debulked Patients - p. 338 145. Secondary Cytoreductive Surgery for Recurrent Disease - p. 338 146. Palliative Surgery Including Surgery for Malignant Bowel Obstruction - p. 339 147. References - p. 340 148. 8.7 Ovarian Cancer: Pathology - p. 342 149. Classification - p. 343 150. Intraoperative Consultation (Frozen Section) - p. 343 151. College of American Pathologists, 2020 World Health Organization, and International Collaboration on Cancer Reporting Guidelines - p. 344 152. Cytopathology - p. 345 153. Borderline Tumors - p. 346 154. Primary Versus Metastatic Ovarian Carcinomas - p. 346 155. Serous Tumors - p. 347 156. Mucinous Tumors - p. 352 157. Endometrioid Tumors - p. 354 158. Seromucinous Tumors - p. 356 159. Clear Cell Ovarian Tumors - p. 357 160. Brenner Tumors - p. 358 161. Mixed Epithelial Ovarian Tumors - p. 359 162. Carcinosarcoma - p. 359 163. Mesonephric-Like Adenocarcinoma - p. 360 164. Other Ovarian Tumors - p. 361 165. Tumors of the Fallopian Tubes - p. 361 166. References - p. 361 167. 8.8 Epithelial Ovarian Cancer: Prognostic Factors - p. 365 168. Tumor Stage - p. 366 169. Age - p. 366 170. Prognostic Variables in Early-Stage Disease - p. 366 171. Prognostic Variables in Stage III/IV Disease - p. 368 172. References - p. 370 173. 8.9 Management of Early-Stage Ovarian Cancer - p. 370 174. Management of Early-Stage (I and II) Ovarian Cancer - p. 371 175. Early-Stage Fallopian Tube Carcinomas and Serous Tubal Intraepithelial Carcinomas - p. 374 176. References - p. 374 177. 8.10 Management of Borderline Tumors and Low-Grade Serous Tumors - p. 375 178. Early-Stage Borderline Tumors - p. 375 179. Advanced-Stage Serous Borderline Tumors - p. 377 180. Therapy for Advanced-Stage Low-Grade Serous Cancers and Invasive Recurrences of Serous Borderline Tumors - p. 377 181. References - p. 377 182. 8.11 Management of Advanced-Stage Ovarian Cancer - p. 378 183. Surgery - p. 378 184. Chemotherapy - p. 379 185. Platinum Use - p. 380 186. Addition of Paclitaxel to Platinum Chemotherapy - p. 380 187. Alternate Paclitaxel Dosing - p. 380 188. Alternate Taxanes - p. 382 189. Addition of a Third Cytotoxic Agent to Frontline Chemotherapy - p. 382 190. Substitution of an Alternate Cytotoxic Agent for Paclitaxel - p. 382 191. Addition of Bevacizumab to Primary Chemotherapy - p. 382 192. Intraperitoneal Chemotherapy - p. 383 193. Consolidation/Maintenance - p. 385 194. References - p. 387 195. 8.12 Approach to Advanced and Recurrent Clear Cell, Mucinous, or Endometrioid Cancer - p. 389 196. 8.13 Treatment of Ovarian Carcinosarcoma - p. 391 197. 8.14 Ovarian Cancer: Survivorship Issues - p. 391 198. 8.15 Treatment of Persistent and Recurrent Ovarian Cancer and Palliative Care - p. 393 199. 8.16 New Therapeutics - p. 398 200. Antibody-Drug Conjugates - p. 398 201. Cell Cycle Checkpoint Kinase Inhibitors - p. 398 202. GAS6/AXL Pathway - p. 398 203. Immunologic Therapies - p. 398 204. References - p. 399 205. SECTION 9: OVARIAN GERM CELL TUMORS - p. 401 206. 9.1 Ovarian Germ Cell Tumors: Introduction, Anatomy, Natural History, and Patterns of Spread - p. 402 207. Introduction - p. 403 208. Anatomy - p. 403 209. Natural History - p. 403 210. Patterns of Spread - p. 404 211. References - p. 404 212. 9.2 Malignant Ovarian Germ Cell Tumors: Etiology, Epidemiology, Risk Factors, Genetics, and Molecular Biology - p. 405 213. Etiology - p. 405 214. Epidemiology and Risk Factors - p. 405 215. Genetics - p. 406 216. Molecular Biology - p. 407 217. References - p. 408 218. 9.3 Ovarian Germ Cell Tumors: Clinical Presentation and Diagnostic Evaluation and Workup - p. 409 219. Clinical Presentation - p. 409 220. Diagnostic Evaluation/Workup - p. 410 221. References - p. 412 222. 9.4 Surgery for Ovarian Germ Cell Tumors - p. 414 223. Goal of Primary Surgery - p. 414 224. Operative Findings - p. 414 225. Route of Primary Surgery - p. 415 226. Extent of Primary Surgery and Surgical Staging - p. 415 227. Cytoreductive Surgery - p. 416 228. Fertility Preservation - p. 417 229. Managing the Unstaged Patient - p. 417 230. Second-Look Surgery - p. 417 231. Secondary Cytoreduction - p. 418 232. Differences in Pediatric and Adult Paradigms - p. 418 233. References - p. 418 234. 9.5 Ovarian Germ Cell Tumors: Pathology and Prognostic Factors - p. 419 235. 9.6 Therapy for Ovarian Germ Cell Tumors: Radiation, Chemotherapy, Targeted Therapy, Immunotherapy, and Other New and Novel Agents - p. 429 236. Evolution of Chemotherapy - p. 429 237. Previous Use of Radiation Therapy in Dysgerminoma - p. 432 238. Adjuvant Treatment by Risk and Histology - p. 432 239. Targeted Therapy, Immunotherapy, and Other New and Novel Agents - p. 434 240. References - p. 434 241. 9.7 Treatment of Persistent and Recurrent Ovarian Germ Cell Tumors - p. 436 242. Management of Residual or Recurrent Disease - p. 436 243. Targeted Therapy, Immunotherapy, and Other New and Novel Agents - p. 437 244. References - p. 437 245. 9.8 Ovarian Germ Cell Tumors: Special Conditions - p. 438 246. Gliomatosis Peritonei - p. 438 247. Growing Teratoma Syndrome - p. 439 248. References - p. 440 249. 9.9 Ovarian Germ Cell Tumors: Follow-Up and Survivorship Issues - p. 440 250. 9.10 Ovarian Germ Cell Tumors: Future Directions - p. 444 251. Surgery and Staging - p. 444 252. Molecular Testing - p. 444 253. Adjuvant Therapy - p. 444 254. Surveillance - p. 446 255. Strategies for Research - p. 446 256. References - p. 446 257. SECTION 10: OVARIAN SEX CORD-STROMAL TUMORS - p. 447 258. 10.1 Ovarian Sex Cord-Stromal Tumors: Introduction, Anatomy, Natural History, and Patterns of Spread - p. 448 259. 10.2 Ovarian Sex Cord-Stromal Tumors: Etiology, Epidemiology, Risk Factors, Genetics, and Molecular Biology - p. 449 260. Incidence and Mortality - p. 450 261. Etiology and Risk Factors - p. 450 262. Genetics - p. 451 263. Molecular Biology - p. 451 264. References - p. 452 265. 10.3 Ovarian Sex Cord-Stromal Tumors: Clinical Presentation, Diagnostic Evaluation, and Workup - p. 453 266. Clinical Presentation - p. 453 267. Evaluation/Workup - p. 454 268. References - p. 455 269. 10.4 Surgery for Ovarian Sex Cord-Stromal Tumors - p. 456 270. 10.5 Ovarian Sex Cord-Stromal Tumors: Pathology and Prognostic Factors - p. 457 271. 10.6 Therapy for Ovarian Sex Cord-Stromal Tumors: Radiation, Chemotherapy, Targeted Therapy, Immunotherapy, and Other New and Novel Agents - p. 464 272. Chemotherapy—Adjuvant Treatment - p. 464 273. Chemotherapy—Advanced-Stage Disease - p. 465 274. Radiation - p. 465 275. References - p. 465 276. 10.7 Treatment of Persistent or Recurrent Sex Cord-Stromal Tumors - p. 466 277. Secondary Cytoreductive Surgery - p. 466 278. Endocrine Therapy - p. 467 279. References - p. 468 280. 10.8 Ovarian Sex Cord-Stromal Tumors: Special Conditions - p. 468 281. 10.9 Ovarian Sex Cord-Stromal Tumors: Follow-Up and Survivorship Issues - p. 469 282. 10.10 Ovarian Sex Cord-Stromal Tumors: Future Directions - p. 470 283. SECTION 11: BREAST CANCER - p. 473 284. 11.1 Breast Cancer: Introduction - p. 474 285. 11.2 Breast Cancer: Epidemiology, Risk Factors, Anatomy, and Natural History - p. 475 286. Epidemiology - p. 475 287. Risk Factors - p. 475 288. Anatomy - p. 476 289. Natural History of Breast Cancer - p. 477 290. References - p. 477 291. 11.3 Breast Cancer: Clinical Presentation - p. 478 292. Introduction - p. 478 293. Physical Examination - p. 479 294. Staging - p. 479 295. References - p. 484 296. 11.4 Breast Imaging - p. 485 297. Screening Guidelines - p. 485 298. Mammography and Digital Breast Tomosynthesis - p. 485 299. Breast Ultrasound - p. 486 300. Emerging Modalities in Breast Imaging - p. 488 301. References - p. 489 302. 11.5 Breast Pathology - p. 489 303. Benign Epithelial Changes - p. 490 304. Carcinoma in Situ - p. 492 305. Invasive Breast Carcinoma - p. 494 306. Other Tumors - p. 497 307. Breast Cancer Biomarkers - p. 498 308. Hormonal Receptors - p. 499 309. HER2 - p. 499 310. Other Markers - p. 500 311. Genomic Studies and Breast Cancer Subtypes - p. 501 312. Conclusion - p. 501 313. References - p. 501 314. 11.6 Surgical Management of the Breast - p. 502 315. In Situ Disease - p. 502 316. Early Invasive Disease - p. 503 317. Locally Advanced Breast Cancer - p. 503 318. Surgery for Inflammatory Breast Cancer - p. 504 319. Oncoplastic Breast Surgery - p. 504 320. Aesthetic Flat Closure and Contralateral Prophylactic Mastectomy - p. 506 321. References - p. 506 322. 11.7 Surgical Management of the Axilla - p. 507 323. Management of the Clinically and Pathologically Negative Axilla - p. 507 324. Technique of Axillary Lymph Node Dissection - p. 510 325. References - p. 510 326. 11.8 Endocrine Therapy for Breast Cancer - p. 511 327. Endocrine Therapy for Newly Diagnosed Hormone Receptor–Positive Disease - p. 512 328. Agents and the Duration of Treatment in the Adjuvant Setting - p. 513 329. Ovarian Ablation or Suppression - p. 515 330. Cyclin-Dependent Kinase Inhibitors - p. 515 331. Neoadjuvant Endocrine Therapy - p. 515 332. Endocrine Therapy for Risk Reduction - p. 516 333. References - p. 516 334. 11.9 Approaches to Systemic Therapy for Breast Cancer: Neoadjuvant and Adjuvant Management - p. 517 335. Neoadjuvant Chemotherapy - p. 518 336. Chemotherapy Regimens - p. 519 337. References - p. 522 338. 11.10 Radiation Therapy for Breast Cancer - p. 522 339. Breast-Conserving Therapy - p. 523 340. Postmastectomy Radiation Therapy - p. 523 341. Radiation Therapy to the Regional Lymph Nodes - p. 524 342. Radiation Therapy After Neoadjuvant Chemotherapy and Surgery - p. 524 343. Radiation Therapy for in Situ Breast Disease - p. 525 344. De-Escalation of Radiation Therapy - p. 525 345. Radiation Therapy: Other Indications - p. 526 346. Radiation Therapy Techniques - p. 527 347. References - p. 528 348. 11.11 Multidisciplinary Approach to Breast Cancer Care - p. 529 349. 11.12 Systemic Treatment for Metastatic Breast Cancer - p. 532 350. The Role of Chemotherapy and Systemic Agents - p. 532 351. Duration of Treatment in Metastatic Disease - p. 535 352. References - p. 535 353. 11.13 Breast Cancer in the Older Patient - p. 536 354. Adjuvant Chemotherapy - p. 537 355. Adjuvant Endocrine Therapy - p. 538 356. Surgical Management and Radiation Oncology in the Older Patient - p. 538 357. References - p. 538 358. 11.14 Pregnancy-Associated Breast Cancer - p. 539 359. Background and Epidemiology of Pregnancy-Associated Breast Cancer - p. 539 360. Treatment Approach to Pregnancy-Associated Breast Cancer - p. 540 361. Outcomes for Patients With Pregnancy-Associated Breast Cancer - p. 541 362. Pregnancy After Breast Cancer Treatment - p. 541 363. References - p. 542 364. 11.15 Breast Cancer: Survivorship Issues - p. 543 365. Surveillance - p. 543 366. Side Effects from Endocrine Therapy - p. 544 367. Pain and Neuropathy - p. 545 368. Molecular-Targeted Therapies - p. 545 369. References - p. 546 370. SECTION 12: SPECIAL TOPICS - p. 551 371. 12.1 Clinical Trials Methodology and Analysis - p. 552 372. Classification of Study Designs - p. 553 373. Components of a Clinical Trial - p. 553 374. Phases of Therapeutic Intervention Trials - p. 556 375. Hypothesis Test - p. 560 376. Translational Research - p. 562 377. Developing Translational Research Studies and Reporting Results - p. 565 378. Clinical Trials Involving Targeted Therapies - p. 566 379. Conclusion - p. 568 380. Acknowledgments - p. 568 381. References - p. 568 382. 12.2 Cost-Effective and Value-Based Gynecologic Cancer Care - p. 570 383. Overview of Cost, Quality, and Value in Health Care - p. 571 384. Defining and Measuring Value in Oncology - p. 571 385. Principals of Health Economic Analyses - p. 574 386. Input Development for Health Economic Models - p. 576 387. Modeling Approaches to Reducing Mortality From Gynecologic Cancers - p. 578 388. Questions Addressed by Cervical Cancer Models - p. 579 389. Cost-Effectiveness of Therapeutics in Gynecologic Cancers - p. 582 390. Chapter Summary - p. 585 391. References - p. 585 392. 12.3 Perioperative and Critical Care - p. 589 393. Introduction - p. 590 394. Preoperative Risk Assessment - p. 590 395. Cardiac Risk Assessment - p. 592 396. Pulmonary Risk Assessment - p. 593 397. Endocrinologic Risk Assessment - p. 593 398. Renal Risk Assessment - p. 598 399. Hepatic Risk Assessment - p. 599 400. Preoperative Nutritional Assessment - p. 600 401. Preparation for Surgery - p. 603 402. Critical Care and Postoperative Management - p. 608 403. References - p. 627 404. 12.4 Nutrition Support of Patients With Gynecologic Cancer - p. 634 405. Introduction - p. 635 406. Nutritional Assessment - p. 635 407. Prevalence of Malnutrition - p. 636 408. Significance of Malnutrition - p. 636 409. Etiology of Malnutrition - p. 637 410. Nutritional Therapies - p. 639 411. Ethical Considerations - p. 646 412. References - p. 646 413. 12.5 Management of Pain - p. 652 414. Introduction - p. 653 415. Assessment of Cancer Pain - p. 653 416. Management of Acute Pain - p. 655 417. Management of Chronic Cancer Pain - p. 657 418. Role of Primary Therapies in Pain Management - p. 657 419. Analgesics Approaches: Pharmacologic Management - p. 658 420. Other Approaches for Chronic Pain Management - p. 669 421. Conclusion - p. 670 422. References - p. 670 423. 12.6 Palliative and Supportive Care - p. 675 424. Introduction - p. 675 425. Systems of Palliative Care Delivery: Specialized Palliative Care, Primary Palliative Care, and Hospice Care - p. 676 426. Primary Palliative Care for the Gynecologic Oncologist - p. 677 427. Quality of Life - p. 683 428. Barriers to the Use of Palliative Care in Gynecologic Oncology - p. 684 429. Improving Palliative Care for Women With Gynecologic Cancers - p. 685 430. Conclusion - p. 685 431. References - p. 685 432. 12.7 Hereditary Cancer Genetics - p. 688 433. Introduction - p. 688 434. Background and Associated Cancer Risks - p. 688 435. Management of Cancer Probands - p. 690 436. Other Hereditary Syndromes Associated With a Gynecologic Malignancy - p. 691 437. Identification and Management of High-Risk Mutation Carriers - p. 692 438. References - p. 695 439. 12.8 Biologic and Physical Principles of Radiation Oncology - p. 696 440. Radiation Oncology as a Specialty - p. 696 441. Introduction to Radiobiology - p. 697 442. Introduction to Radiation Physics - p. 704 443. Radiation Production - p. 705 444. Clinical Applications - p. 715 445. External Beam Irradiation for Gynecologic Cancers - p. 715 446. Intracavitary Applicators: Cervical Cancer - p. 729 447. Future Focus - p. 742 448. References - p. 743 449. Index - p. 750