The rationale of opportunistic bilateral salpingectomies (OBS) during benign gynaecological and obstetric surgery: a consensus text of the Flemish Society of Obstetrics and Gynaecology (VVOG).

Ovarian cancer (OC), is a disease difficult to diagnose in an early stage implicating a poor prognosis. The 5-year overall survival in Belgium has not changed in the last 18 years and remains 44 %. There is no effective screening method (secondary prevention) to detect ovarian cancer at an early stage. Primary prevention of ovarian cancer came in the picture through the paradigm shift that the fallopian tube is often the origin of ovarian cancer and not the ovary itself. Opportunistic bilateral salpingectomy (OBS) during benign gynaecological and obstetric surgery might have the potential to reduce the risk of ovarian cancer by as much as 65 %. Bilateral risk-reducing salpingectomy during a benign procedure is feasible, safe, appears to have no impact on the ovarian function and seems to be cost effective. The key question is whether we should wait for a RCT or implement OBS directly in our daily practice. Guidelines regarding OBS within our societies are therefore urgently needed. Our recommendation is to inform all women without a child wish, undergoing a benign gynaecological or obstetrical surgical procedure about the pro's and the con's of OBS and advise a bilateral salpingectomy. Furthermore, there is an urgent need for a prospective registry of OBS. The present article is the consensus text of the Flemish Society of Obstetrics and Gynaecology (VVOG) regarding OBS.

HPV vaccination coverage in the federal state of Belgium according to regions and their impact.

Long-term results of the HPV vaccination programs in Australia and Scotland have shown a tremendous impact on the reduction of HPV infection rates and precancerous diseases. Both countries started mass vaccination ten years (Australia) and eight years (Scotland) ago and achieved a vaccination coverage of more than 80 %. Within 20 to 30 years a reduction in cervical cancer by more than 75 % is expected. Furthermore, there will be a reduction in other HPV related cancers like vaginal, vulva, perineal, anal and oropharyngeal cancers. In order to be successful, a high vaccination coverage is needed. In Belgium, the vaccination was introduced in 2010 in the Flemish community and in 2011 in the French community. In the first vaccinated cohorts the coverage in Flemish and French Communities was respectively 84% (2010) and 29% (2012-2013). The latest data suggest that the Flemish Community (Flanders Region) attained a coverage of 91 % while the French Community (Walloon Region) attained a coverage of around 36 %. The regional difference in coverage offers a real-life case. The worst-case scenario could end up with proportionally one half of country having more HPV related cancers than the other half. Currently efforts are performed to increase the coverage rates in both regions and consequently decreasing this difference. Additionally, the updated recommendations regarding the HPV vaccination by the Belgian NITAG (National Immunization Technical Advisory Group) stated that the HPV vaccination should be gender neutral. This could stimulate the vaccination program and increase the coverage. The coverage rate in Flanders is among the highest in the world and the rate in the French Community is increasing. Efforts should be continued in order to maintain trust and increase the coverage rate.

HPV negative cervical cancers and primary HPV screening.

More than 25 years ago it was established that a HPV (Human Papilloma Virus) infection was the causal factor for cervical cancer. Based on this discovery HPV vaccines were developed and primary HPV screening proposed. The impact of 10 years prophylactic HPV vaccination with the bivalent and quadrivalent vaccines has been tremendous. There is a reduction of HPV infections 16/18, 31, 33 and 45 of respectively 89%, 94%, 79% and 83%. High grade lesions have been reduced by 85% and warts by 90%. Within 20 to 30 years a reduction in cervical cancer incidence, by 70-80%, is to be expected. The 9 valent HPV vaccine, which was introduced last year and is reimbursed for girls between 12 - 19 years, is expected to increase the figures by 14 to 18%. Recently, doubt has been created regarding primary HPV screening. Since 2017, the annual screening report in Belgium suggests that 15% of the cervical cancers were HPV negative. Previous published data in Belgium (period 2001 - 2008) showed that the number of HPV negative tumors is less than half of the suggested figure (7%). Frequent reasons for false negative HPV tumors are the used HPV testing methods and the misclassification of endometrial cancers or metastasis as cervical cancers. Other explanations are the loss of HPV expression and the existence of cervical cancers independent of HPV. The incidence of HPV negative tumors doesn't give any information about the performance of primary HPV screening. Data from randomized controlled trials are very clear: if a woman has a normal cytology and no HPV infection or normal cytology and a HPV infection, then her chance of developing a CIN3 + lesion after 5 years is, respectively, 0,2% and 6%. In Belgium, primary HPV screening with dual-stain cytology triage would considerably reduce the incidence (36%) and mortality (40%) of cervical cancer. There is necessity to improve the screening as we are entering an era of vaccinated women who will get screened. Standardized high quality HPV testing is the key stone for improvement. HPV screening preferable with triage markers is superior to cytology, despite the fact that there are HPV negative cancers. The fact that there are HPV negative cancers should not undermine all idea's regarding primary HPV screening.

The exploding tumour on breast magnetic resonance imaging: an infected skin comedo.

A 61-year-old woman with a histologically proven invasive lobular carcinoma entered a clinical trial, which involved repeat magnetic resonance imaging (MRI). The protocol of the repeated MRI described a T4 breast cancer with involvement of the skin (Fig 1). There were only 17 days between the first and second MRI and during this short time it appeared that there had been rapid disease progression. On the initial MRI, a skin comedo could be seen in the left breast close to the tumour. The patient had squeezed the skin comedo, which had become infected. The second MRI captured the infected skin comedo, which had the appearance of an extensive breast cancer with skin involvement. The patient could be mismanaged if the clinician does not correlate the clinical findings with the radiological findings.

The smooth and bumpy road of trastuzumab administration: from intravenous (IV) in a hospital to subcutaneous (SC) at home.

Trastuzumab has become standard of care in the treatment of early and metastatic HER2-positive breast cancer. Initially trastuzumab could only be administered intravenously (IV), however since a few years there is also a subcutaneous (SC) formulation. The efficacy and the safety profile of both formulations is the comparable. The administration logistics however have an impact on the patients, the health care professionals (HCPs), the hospital and the government. The preference for the patients (89%) and the HCPs (77%) is in favour of the SC formulation. The patient chair time per cycle, as defined by the time between entry and exit of infusion chair, is between 53 and 122 minutes shorter for SC administration. Also, the time actively dedicated by the HCP on preparation and administration SC, is between 17 and 50 minutes shorter per cycle. These time savings may increase the capacity of an oncological day clinic and reduce waiting lists. An additional benefit is that the use of SC formulation reduces the consumables and the waste. When the SC form was given at home instead of in the hospital the safety profile remained the same, but the satisfaction rate improved further for both the patients and the HCPs. The next and final step will be potentially to invest in teaching the patients to self-administer the medication. The home administration and the education of the patients and the HCPs will have a cost price and it will be interesting to see how the hospital financial authorities and the government will deal with this situation in the time of budgetary restrictions.

Is anti-hormonal treatment in DCIS of the breast a need?

Ductal carcinomas in situ (DCIS) represent one fifth of all detected breast cancers. The detection of DCIS can be regarded as collateral damage of breast cancer screening. The treatment of DCIS is based on surgery with or without radiotherapy. Women treated for DCIS have a 10 years survival of 98 %. Could there be a role for systemic therapy in case of a DCIS? Recent published studies suggest there is. However, anti-hormonal therapy (tamoxifen, anastrozole) in DCIS causes an increased morbidity without a reduced mortality. There is an urgent need for evidence-based guidelines in the management of DCIS in order to make appropriate shared decisions.