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Gynaecological Cancer Care A Guide to Practice 1st
Edition Tish Lancaster (Author) Digital Instant Download
Author(s): Tish Lancaster (Author); Kathryn Nattress (Author)
ISBN(s): 9781498790468, 1315328798
Edition: 1
File Details: PDF, 54.18 MB
Year: 2007
Language: english
Gynecological Cancer Care
A Guide to Practice
Gynecological Cancer Care
A Guide to Practice

Edited by Tish Lancaster and Kathryn Nattress

Foreword by Dame Gill Oliver

Boca Raton London New York

CRC Press is an imprint of the

Taylor & Francis Group, an informa business
First published 2005 by Ausmed Publications Pty Ltd

Published 2018 by CRC Press

Taylor & Francis Group
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Boca Raton, FL 33487-2742

© 2005 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Gynecological Cancer Care Nursing: A Guide to Practice

ISBN 13: 978-0-9752018-0-0 (pbk)

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have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal
responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any
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National Library ofAustralia Cataloguing-in-Publication data

Gynaecological cancer care : a guide to practice.
Bibliography.
Includes index.
ISBN O9752018 0 8.
ISBN 9 78097520 1800.

I. Gynecologic nursing. 2. Generative organs, Female -

Cancer - Nursing -Australia. 3. Generative organs, Female
- Diseases - Nursing - Australia. I. Lancaster, Letitia.
II. Nattress, Kathryn.

618.1
 Contents

Dedication

Acknowledgments

Foreword

Preface

About the Authors

Anatomical Diagrams

Chapter 1 Setting the Scene 1

Tish Lancaster
Chapter 2 Genetic Susceptibility 13
Diane Stirling and Sheila Slater

Chapter 3 Screening 29
Annie Stenlake
Chapter 4 Ovarian Cancer 47
Mary Ryan and Patricia Mackenzie
Chapter 5 Cervical Cancer 63
Catherine Spencer and Huang Fang
Chapter 6 Endometrial Cancer 79
Jayne Maidens
vi
Contents

Chapter 7 Vulvar Cancer 91

Anne Mellon

Chapter 8 Gestational Trophoblastic Disease 105

Kathryn Nattress

Chapter 9 Uncommon Cancers 123

Rosie McCahill, Tish Lancaster, and Georgina Richter

Chapter 10 Chemotherapy 145

Sheila MacBride and Ellen Toms

Chapter 11 Radiotherapy 167

Karima Velji

Chapter 12 Fertility 187

Elizabeth Pearce

Chapter 13 Menopause 201

Gaye Paterson

Chapter 14 Lower Limb Lymphedema 213

Margaret Sneddon

Chapter 15 Stomal Care 235

Julia Thompson

Chapter 16 Urinary Difficulties 255

Anne Sargent

Chapter 17 Psychosocial and Spiritual Care 273

Kim Hobbs and Katharine Smith
Chapter 18 Sexuality and Body Image 289
Rosalind Robertson

Chapter 19 Social and Cultural Diversity 303

Lisbeth Lane

Chapter 20 Palliative Care 313

Anne Morgan

Chapter 21 Advanced Symptom Management 329

Peta McVey

Chapter 22 Loss, Grief, and Bereavement 357

Elizabeth Lobb

References 369

Index 413
 <Dedication
Dedicated to our sisters

Anna and Sara

whose careers have included time as gyn-oncology nurses

Ac^nowCedgments
Many people have contributed to the development o f this book and supported
us throughout the project. Our grateful thanks are extended to:
• the individual chapter authors o f this book, for their commitment
to excellence in the care o f women with gynecological cancer;
• Dame Gill Oliver, for so graciously agreeing to provide the
foreword;
• our work colleagues, for their indulgence o f our obsession with this
all-consuming project; in particular we thank Philip Beale, Amanda
Beaven, Jonathan Carter, Jacqui Gillan, Ilona Juraskova, Barbara
Shaw, and Gerry Wain;
• our families, for having always supported our choice o f career;
• Guy and Oscar, for giving us a reason to turn off the computer and
go home at night; and
• the staff at Ausmed Publications, for their willing support o f our
passion for our craft.

Tish Lancaster
Kathryn Nattress
September 2005
 (foreword
Gill Oliver

‘I don’t feel like a woman any more.’

All manifestations of cancer are iniquitous, but gynecological cancers have

particular potential to create great distress in patients and their loved ones.
Altered body image receives much attention when cancer is being discussed,
but this is most often in the context of breast cancer or in cancers of the head
and neck—in which the bodily changes are often visible. But in gynecological
cancer—for example, in uterine, vulvar, or cervical cancer—changes are
often hidden from view. And women often have difficulty in discussing these
physical, psychological, and emotional changes. Gynecological cancers are
hidden.
Gynecological cancers are poorly represented in the academic
literature, in the mass media, and in day-to-day conversation. For those who
are affected with these diseases, this means that there is less information and
help available to cope with the physical, emotional, and social effects of their
disease. I have known women with cervical cancers whose most intimate
relationships have foundered on the rocks of ignorance, anxiety, and fear.
If the care and support of people who are affected by gynecological
cancers is to improve, those who provide this care require access to the most
up-to-date, comprehensive, and accurate educational and support materials.
Gynecological Cancer Care: A Guide to Practice has been designed to
do just that. The wealth of experience demonstrated by its range of expert
international authors guarantees that each chapter is filled with real practical
information and advice. Those who read it and take its lessons to heart
will certainly enhance the care that they provide for their patients. The
existing literature is woefully sparse, and this book, edited with great skill
by Tish Lancaster and Kathryn Nattress, is a timely and welcome addition.
Foreword

The book covers the full range of women’s cancer—both common and rare—
in an approachable style; and the information is presented in a manner that
allows readers to read from cover to cover, or to use the book as a reference,
according to need.
Treatment, care, and control of cancer require a team effort. That team
consists not only of professionals from a wide range of disciplines, but also
of patients and carers. The real ‘experts’ are the people who have experienced
the effects of gynecological cancer for themselves, and who thus understand
how their care might have been better planned and better delivered. The team
includes nurses and doctors, particularly those with specialist experience
and education, as well as members of allied health professions, including
dietitians, physiotherapists, occupational therapists, social workers, and
chaplains.
I am honoured and privileged to have been asked to write the Foreword
to this text. I do so with great pleasure, and in the certain knowledge that this
book has the potential to make a very real difference to the lives of so many
women who, in the future, will be diagnosed with gynecological cancers. I
warmly recommend and endorse this book as an essential text for all those
who care for women with gynecological cancer.

Dame Gill Oliver

Gill Oliver qualified as a registered nurse at the Middlesex Hospital (London, UK)
in 1965. In 1979 she completed a bachelor’s degree in arts with the Open University,
and subsequently obtained an oncology nursing certificate in 1983. In 1987 Gill was
seconded to the Royal College of Nursing where she held a national role as acting adviser
in oncology nursing, before moving to a regional nursing post with a palliative care
remit. In 1992 she returned to the oncology centre as director of patient services. Gill has
been involved with cancer planning and strategy groups at local and national level and
has been a member of various Department of Health groups, contributing to the Policy
Framework for Commissioning Cancer Services for England and Wales and The NHS
Cancer Plan. In 2000, Gill joined Macmillan Cancer Relief, one of the UK’s largest
cancer-care charities, as director of service development. She continued to contribute
to policy and strategy development both within Macmillan and in partnership with the
Department of Health. In October 2004 Gill retired from her full-time post but continues
to work for Macmillan Cancer Relief as a part-time consultant and adviser for nursing
and allied health professionals. Gill was created Dame Commander of the British Empire
(DBE) in 1998 and made a fellow of the Royal College of Nursing in the same year. In
2004, Dame Gill Oliver was awarded the Gold Medal from Macmillan Cancer Relief.
 (Preface
Tish Lancaster and Kathryn Nattress

The nature and impact of gynecological cancer

The term ‘gynecological cancer’ encompasses a disparate group of diseases
that have various risk factors, clinical features, patterns of management, and
prognoses. These diseases affect women of all ages—adolescents, those of
reproductive years, the middle-aged, and the elderly. Although geographical
variations exist, gynecological cancers affect
women wherever they live. Collectively, they
represent the second most common cancer ‘Jl diagnosis of
in women (after breast cancer) and the most gynecologicalcancer can
common cause of cancer deaths in women threaten a woman’s 6ody
(Ferlay et al. 2004). However, with modem image, fertility, sexuality,
treatment, survival rates are generally high, femininity, relationships,
and these women must live with the sequelae and roles in life.’
of the disease and its treatment. A diagnosis of
gynecological cancer challenges a woman’s self-concept and can threaten her
body image, fertility, sexuality, femininity, relationships, and various roles in
life.
The impact of such disparate diseases varies dramatically. For example,
a woman who is diagnosed with ovarian cancer requires support to help
her and her family cope with the aggressive abdominal surgery that is often
required, complex chemotherapeutic regimens, difficult issues of palliative
care, and preparation for an untimely death. In contrast, a woman who is
diagnosed with cervical cancer is very likely to be cured of her cancer, and
will require quite different support from her professional carers. These (often
young) women have to deal with potential loss of fertility, the possibility of
xii
Preface

bladder and bowel problems, and the impact of the disease on body image
and sexuality.

The need for this book

Having worked with women with gynecological cancer for many years, we
were well aware of the complex and challenging issues with which these
women must cope. We were equally conscious of the limited literature that
is available to support nurses and other health professionals who are called
upon to meet the needs of these women in a diverse range of practice settings.
Although gynecological cancers represent
the second most common group of cancers
,(We were conscious o f in women, the needs of these women are
the CimitedCitemture to frequently unrecognized and often neglected.
support nurses and other Media attention, professional interest, and
heaCth professionals who community support are overwhelmingly
are catted upon to meet focused on women with breast cancer. For
the needs o f these women. ’ example, a literature search in the Cumulative
Index of Nursing and Allied Health Literature
produced 7925 reference citations on ‘breast cancer’ in general and 301 on
‘breast-cancer nursing’ in particular. A similar search for ‘gynecological
cancer’ produced only 55 reference citations on ‘gynecological cancer’ and
none on ‘gynecological-cancer nursing’.
The genesis of this book came from a recognition of this relative
neglect of gynecological cancer, and the project received additional impetus
after an educational needs analysis was undertaken in Sydney (Australia) in
2004. This analysis revealed that nurses had little confidence in addressing
the needs of women with gynecological cancer. They particularly lacked
confidence in dealing with such issues as lymphedema, genetics, fertility,
and sexuality (Maidens et al. 2004). After much discussion and debate, the
concept of Gynecological Cancer Care: A Guide to Practice was developed.

The structure of this book

Gynecological Cancer Care: A Guide to Practice provides a comprehensive,
practical, evidence-based guide to the diagnosis and management of
gynecological cancer from a person-centred perspective. Although the book is
not formally divided into separate sections, the chapters fall into five general
groups.
 xiii
Preface

• Chapters 1, 2, and 3 set the scene. These chapters provide an overview

of the subject, discuss genetic susceptibility, and explore the principles
and practice of screening for gynecological cancer.
• In Chapters 4-9, the book then considers various types o f
gynecological cancer from the perspective of the women who are
living with these cancers. These chapters provide practical advice for
managing the physical, emotional, sexual, and social consequences
of the diseases and their treatment. The objective risk factors,
presentation, treatment, and palliative care of the cancers are also
considered in detail.
• Chapters 10-16 consider the treatment and sequelae of the diseases
in more detail. These chapters discuss such issues as chemotherapy,
radiotherapy, fertility, menopause, lymphedema, stomal care, and
urinary difficulties. The inclusion of the chapters on menopause and
lymphedema is an especially exciting development. Although much
has been published on these issues with respect to women with breast
cancer, this book is one of the few publications to consider them in the
context of women with gynecological cancer.
• Chapters 17-19 concentrate on the psychosocial impact of
gynecological cancers. These chapters discuss psychosocial and
spiritual care, sexuality and body image, and social and cultural
diversity.
• Finally, Chapters 20-22 address end-of-life care. The chapters discuss
the practical and ethical issues of palliative care, advanced symptom
management, and loss, grief, and bereavement.
This outline of the framework of the book reflects the fact that the
issues faced by women with gynecological cancer are often multifactorial in
aetiology, diagnosis, and management. Nurses and other health professionals
thus require resources that cover a range of issues in depth and breadth if they
are to provide comprehensive care. This book provides such a rich resource
of material—presented in a stimulating, practical, evidence-based, person-
centred manner.

Enriching and empowering

The production of such a comprehensive multidisciplinary volume requires
the helpful collaboration of a wide range of people. Gynecological Cancer
Care: A Guide to Practice is a high-quality, international textbook featuring
xiv
Preface

expert contributions from 28 health professionals from a range of disciplines

in six countries. Each of these chapter authors is a clinical expert in her field,
and this has ensured that current research knowledge and clinical expertise
come together to provide readers with practical, evidence-based guidance to
inform their professional care of women with gynecological cancer.
We are very grateful to all contributors for their expert assistance and
helpful collaboration. When we began this project, we believed that our long
experience as cancer nurses meant that we possessed extensive knowledge
of the myriad issues involved in the care of women with gynecological
cancer. However, as we have progressed
in this project, we have found that our
‘‘Enrich and empower knowledge base has been greatly enriched
health professionals... to by the contributions of the individual
caterfo r the needs o f women chapter authors. We have certainly become
ivith renewedprofessional aware of the truth of Benjamin Disraeli’s
expertise, confidence, insightful remark: ‘The best way to become
and compassion. ’ acquainted with a subject is to write a book
about it’!
We feel excited and privileged to be able to present this book. We
trust that Gynecological Cancer Care: A Guide to Practice will enrich and
empower health professionals who care for women with gynecological
cancer, and that the book will thus equip them to cater for the needs of these
women with renewed professional expertise, confidence, and compassion.
 JL6out the Authors
Huang Fang
Chapter 5
Huang Fang is a registered nurse and midwifery staff nurse. She holds a certificate
in gynecological oncology nursing, an advanced diploma in oncology nursing, and a
bachelor’s degree in nursing. Fang worked as a midwife staff nurse, senior staff nurse,
and clinical nurse educator in China until April 1994. In 1994, she joined the KK
Women’s and Children’s Hospital (Singapore). Fang has worked as an oncology nurse
and senior oncology nurse in the Gynaecological Oncology Unit for more than ten
years. She is a member of the Procedure Improvement Program of the Gynaeoncology
Division and a member of the Oncology Support Working Party. In 2004, she was
selected for the HMDP Fellowship by SingHealth of Singapore and was awarded a three-
month training fellowship at the Royal Hospital for Women in Sydney (Australia).

Kim Hobbs
Chapter 17
Kim Hobbs is a social worker who holds a master’s degree in social work. She is a
member of the Australian Association of Social Workers and the Clinical Oncological
Society of Australia. For thirteen years, Kim worked as an oncology social worker in
Sydney (Australia) at Royal Prince Alfred Hospital and at Sydney Hospital. For the
past ten years she has been working at the Westmead Centre for Gynaecological Cancer
(Sydney, Australia). Kim has a particular interest in the issues and concerns of women
with cancer. In addition to her clinical work at Westmead, Kim serves on a number of
committees and working parties advocating the importance of psychosocial care as
an integral component of comprehensive cancer care. She is currently a member of a
multidisciplinary collaborative research team that is undertaking a series of projects
investigating the effectiveness o f cancer support groups.

Tish Lancaster
Subject specialist editor, Chapters I and 9
Tish Lancaster is a registered nurse who holds an oncology certificate and bachelor’s
degree in health science (nursing). She is a fellow of the College of Nursing (NSW)
and a fellow of the Royal College of Nursing, Australia. Tish is the deputy chairperson
of the Cancer Nurses Society of Australia and the chairperson of the society’s Research
xvi
About the Authors

Advisory Committee. She has worked as a cancer nurse in Sydney for more than
20 years—as a clinical nurse specialist on the Oncology Unit Chemotherapy Team
at Royal Prince Alfred Hospital, as the nursing unit manager of the Oncology Ward
and Day Chemotherapy Unit at Prince of Wales Hospital, and in her current position
as the clinical nurse consultant for gynecological oncology at Westmead Hospital.
Tish is a member of the editorial board of Cancer Forum, the journal of the Clinical
Oncological Society of Australia, a member of the New South Wales Cancer Institute’s
Patient Support Working Party, and a member of the Cancer Council’s New South
Wales Cancer Trials Centre Selection Committee. Tish was the chair of a working party
of the International Society of Nurses in Cancer Care which was established to develop
a position statement on cervical cancer screening (published in 2001). She is also a
member of a working party of the Australian Cancer Network to develop the recently
released Guidelines for the Management of Epithelial Ovarian Cancer, endorsed by the
National Health and Medical Research Council.

Lisbeth Lane
Chapter 19
Lisbeth Lane is a registered psychologist. She holds bachelor’s degrees in education
and arts, and a PhD in psychology. Her doctoral thesis addressed the psychological
support needs of women living with cancer. As an honorary fellow of the University
of Wollongong (Australia) she lectures in the Department of Health and Behavioural
Sciences on psychological issues related to diagnoses of cancer and other chronic
diseases. Lisbeth has provided individual and group interventions for adults with cancer
in hospital and community-health settings and in private practice. She is a member of
the Clinical Oncological Society of Australia and has presented widely at national and
international conferences on the psychosocial issues of women with cancer. She has
been published in peer-reviewed journals and has written chapters for psychological
theory texts. Lisbeth is in clinical practice at Liverpool Hospital in Sydney (Australia)
as a member of a multidisciplinary team working in gynecological oncology and is
conducting research on perceptions of a gynecological cancer diagnosis in a culturally
and linguistically diverse population.

Elizabeth Lobb
Chapter 22
Elizabeth Lobb has 13 years clinical, teaching, and research experience in cancer
medicine. She holds a PhD in psychological medicine, a master’s degree in applied
science, and a bachelor’s degree in adult education. Liz is currently a post-doctoral
research fellow in the Western Australian Centre for Cancer and Palliative Care. Her
research and clinical interests include the psychological impact of cancer, factors
influencing coping and adjustment, genetic counselling in familial breast and ovarian
cancer, and loss, grief, and bereavement in life-threatening illness. Liz has taught
bereavement counselling in the government, welfare, and private sectors for 10 years.
Before moving to Perth (Western Australia) in January 2004, she worked as a visiting
 xvii
About the Authors

bereavement counsellor at the Mater and Royal Prince Alfred Hospitals in Sydney, and
was a staff and patient counsellor at Sacred Heart Hospice. Liz spent six years at the
Prince of Wales Hospital in adolescent and paediatric oncology, and six years at Royal
Prince Alfred Hospital in the Medical Psychology Research Unit where she completed
her Masters and PhD.

Sheila MacBride
Chapter 10
Sheila MacBride is a registered nurse with a bachelor’s degree in nursing, a master’s
degree in cancer nursing, and a postgraduate certificate in teaching and learning in
higher education. Her master’s thesis focused on survivorship and follow-up issues
in young men who received chemotherapy for testicular cancer. Sheila has worked
as a cancer nurse in Scotland for twenty years, holding posts as charge nurse, clinical
nurse specialist, and clinical nursing (education) facilitator. She developed a nurse-led
chemotherapy service in South-East Scotland. For the past two years she has been a
lecturer in cancer nursing at the University of Dundee where she delivers nurse education
at preregistration, postregistration, and postgraduate levels in adult and specialist
cancer-nursing programs. She is a keen researcher, most recently in the area of radiation
skin reactions, and has published and presented nationally and internationally. Sheila
has been involved in the development of a best-practice statement in radiation skin
reactions with an expert multidisciplinary group for National Health Service Quality
Improvement Scotland. Her recent initiatives include involving patients in discussions
within online education modules for safe administration of cytotoxic chemotherapy to
illustrate their perspectives on the chemotherapy experience.

Patricia Mackenzie
Chapter 4
Patricia Mackenzie is a registered nurse and certified midwife who holds an oncology
certificate and a bachelor of arts degree. She has worked as a cancer nurse for 18 years,
including 12 years as a registered nurse in gynecological oncology at Royal Prince
Alfred Hospital (Sydney, Australia) and six years in her current position as clinical
nurse consultant in gynecological oncology at the Royal Hospital for Women (Sydney).
Her role has included caring for women in surgical settings, the administration of
chemotherapy and brachytherapy, and palliative care. Patricia has been involved in a
research study looking at the prevalence and experience of lower-limb lymphedema
among women following treatment for gynecological cancer. She is a member of the
executive committee of the Sydney branch of the Cancer Nurses Society of Australia.

Jayne Maidens
Chapter 6
Jayne Maidens is a registered nurse and registered midwife who holds a certificate
in oncology, a bachelor’s degree in nursing, and a master’s degree in public health.
xviii
About the Authors

Her master’s project focused on the surgical treatment of endometrial cancer. On

completion of her general nursing training, Jayne spent two years in Scotland where she
trained as a midwife. She has since worked as a cancer nurse in Sydney (Australia) for
more than 20 years. Her roles have included clinical nurse specialist in gynecological
oncology at Royal Prince Alfred Hospital, clinical nurse consultant in gynecological
oncology at Liverpool Health Service, and her current position as the clinical nurse
consultant in gynecological oncology at Royal North Shore Hospital. Jayne was
publicity officer for the Sydney regional group of the Cancer Nurses Society of Australia
(CNSA) and she is the co-chair of the Greater Metropolitan Clinical Taskforce (GMCT)
Gynaecological Oncology Group. She was a member of the steering committee of
the Psychosocial Support Project, which developed a website to provide supportive
information for women diagnosed with gynecological cancers, their partners, carers,
family, and friends.

Rosie McCahill
Chapter 9
Rosie McCahill has been the clinical nurse specialist for gynecology in the Beatson
Oncology Centre (Glasgow, Scotland) since 1998. This role has a large clinical
component, and involves developing and implementing nurse-led services including a
consultancy service for patients and healthcare professionals. The role also includes the
development of academic courses for nurses and healthcare professionals. Rosie has
previously worked in surgical cancer centres for gynecological oncology in Glasgow
and Edinburgh. While working in Edinburgh, Rosie graduated from the University of
Edinburgh with a master’s degree in cancer nursing. She is also an honorary lecturer and
course director in radiotherapy and brachytherapy at Glasgow Caledonian University.
Rosie is a past president of the UK National Gynaecological Oncology Nursing Forum,
and remains an active member of this forum on a local and international level.

Peta McVey
Chapter 2 1
Peta McVey is a registered nurse who holds an oncology certificate, a graduate certificate
in clinical trials management, a graduate diploma in palliative care, and master’s degree
in nursing (research). Her master’s thesis focused on the prevalence and experience of
anxiety and depression among community palliative-care patients. Peta has worked as
a cancer nurse for more than 20 years—as a clinical nurse specialist in gynecological
oncology at Royal Prince Alfred Hospital (Sydney, Australia), a clinical nurse specialist
in palliative care at Sacred Heart Hospice (Sydney) and, for the past six years, in her
current position as the clinical nurse consultant and coordinator of the community
palliative-care outreach service at Neringah Hospital (Sydney). Peta is a member of
both the Royal College of Nursing, Australia and the College of Nursing (NSW). She
has a commitment to education, has several publications to her credit, and has been
involved in several multicentre studies. She is currently working with the National
 xix
About the Authors

Medication Breakthrough Collaborative reviewing safe and appropriate use of opioids

in the community setting.

Anne Mellon
Chapter 7
Anne Mellon is a registered nurse who holds a bachelor’s degree in nursing, a graduate
certificate in gynecology nursing, a graduate certificate in cancer nursing, and a
graduate diploma in cancer nursing. She has worked in gynecological oncology for 12
years, beginning as a ward nurse at Royal North Shore Hospital (Sydney, Australia).
Since 1996, Anne has been the gynecological oncology clinical nurse consultant at the
Hunter Centre for Gynaecological Cancer, John Hunter Hospital (Newcastle, Australia).
Anne is involved in research in gynecological oncology, with a particular interest in
the treatment and care of women with vulvar cancer. Anne is an active member of
the Cancer Nurses Society of Australia and has held various positions in the Hunter
Regional Group, including chairperson in 2005-2006.

Anne Morgan
Chapter 20
Anne Morgan is a registered nurse who works as the palliative-care nurse consultant
at Christchurch Hospital, New Zealand. She holds a postgraduate certificate in
palliative care and a postgraduate diploma in health sciences, and is completing her
master’s degree. Anne has worked in the area of oncology and palliative care for more
than 25 years in New Zealand and the United Kingdom. She helped to develop the
Christchurch Hospital Palliative Care Service in 1999. She is also involved in graduate
and postgraduate education and runs a communication business providing workshops
for health professionals and for people who have life-threatening illness. Anne has
developed a hospital palliative-care website to provide specialist palliative-care
knowledge to health professionals and patients. She has also developed a number of
guidelines and protocols for palliative care in acute-care settings. Anne has represented
the nursing profession on several regional and national groups and is currently an
executive committee member of the Canterbury/West Coast division of the Cancer
Society of New Zealand.

Kathryn Nattress
Subject specialist editor, Chapter 8
Kathryn Nattress is a registered nurse and holds a bachelor’s degree in science
(nursing) and a master’s degree in medical science (palliative care). Her master’s thesis
focused on the experiences of women living with advanced ovarian cancer, and she
holds specialist practitioner registration in palliative care. Kathryn has worked as a
cancer nurse in Scotland and Australia for more than ten years. In Scotland she was a
Macmillan clinical nurse specialist in palliative care and in gynecological oncology.
She was also employed as an information officer at Cancerlink—a national charity
XX
About the Authors

providing information and support to cancer patients. Since moving to Australia in

2002, Kathryn has been employed in her current position as the clinical nurse consultant
for gynecological oncology at the Sydney Cancer Centre. Kathryn has provided nursing
representation on a variety of national working parties. As a member of the Clinical
Standards Board for Scotland—Gynaecological Cancer Group, she was involved in
the development and implementation of a national system of quality assurance and
accreditation and, as a member of the Scottish Intercollegiate Guidelines Network—
Epithelial Ovarian Cancer Group, she was involved in the development of evidence-
based guidelines for the management of this disease. Kathryn is a member of the
editorial advisory board for the Virtual Cancer Centre website.

Ga/e Paterson
Chapter 13
Gaye Paterson is a registered nurse who holds bachelor’s and master’s degrees in
nursing. Her master’s dissertation explored women’s experiences of menopausal
symptoms during adjuvant treatment for breast cancer. Gaye has worked as a cancer
nurse since 1989, and has held posts in acute-care and palliative-care settings in Scotland
and England. She worked as a clinical nurse specialist in breast care, before taking up
a joint academic and clinical appointment with the University of Glasgow. Since 2003
Gaye has been based at the Cancer Care Research Centre (CCRC) in the University
of Stirling (Scotland). Gaye has presented papers at national and international cancer
conferences, and has published articles on a range of cancer-care issues. She was
involved in developing evidence-based guidelines for the management of breast cancer
for the Scottish Intercollegiate Guideline Network (SIGN), and was also a co-author of
an educational resource for nurses in biological therapies and cancer that was developed
in collaboration with the European Oncology Nursing Society. Gaye is a member of the
review panel for papers submitted to the International Journal o f Palliative Nursing.

Elizabeth Pearce
Chapter 12
Elizabeth Pearce is a registered nurse and certified midwife. She holds a bachelor’s
degree in health science nursing, a graduate certificate in counselling, and a graduate
certificate in research (health). Elizabeth has worked as a fertility nurse for 16 years.
For the past nine years she has been the clinical nurse consultant at the Westmead
Fertility Centre, Westmead Hospital (Sydney, Australia). She is a nurse representative
on the Australian Reproductive Technology Accreditation Committee and has recently
been a member of a private auditing team conducting a review of fertility services in
Japan. Elizabeth is the author of the reproductive medicine module of the advanced
midwifery course of the College of Nursing (NSW). She has a particular interest in
fertility preservation for cancer patients, and has presented on this topic at national
conferences.
 xxi
About the Authors

Georgina Richter
Chapter 9
Georgina Richter is a registered nurse at the Royal Adelaide Hospital (South Australia).
After completing her nursing training at the hospital in 1992, she went on to work
in urology and gynecological oncology for the following 11 years. She has held the
position of gynecological oncology clinical support nurse at the Royal Adelaide
Hospital since 2003.

Rosalind Robertson
Chapter 18
Rosalind Robertson holds a master’s degree in arts (psychology) and is a member of
the Australian Psychological Society and the International Psycho-Oncology Society.
She has worked in the field of women’s health for more than 20 years, and has a special
interest in the psychosexual aspects of gynecological cancer. Rosalind initially worked
in the Menopause Centre at the Royal Hospital for Women (Sydney), where she was
involved in counselling and research on the psychological aspects of menopause. She
has held a full-time position as psychologist in the Gynaecological Cancer Centre at the
Royal Hospital for Women since 1990. Rosalind has been involved in the publication
of articles on the subject and has delivered papers at numerous conferences around the
world. She is also involved in the teaching and training of allied health professionals
who are involved in the practice of psycho-oncology.

Mary Ryan
Chapter 4
Mary Ryan is a registered nurse and certified midwife who holds an oncology certificate
and a bachelor’s degree in nursing with honours. Her honours thesis and her current
PhD thesis have both focused on the experiences of women with recurrent ovarian
cancer. Mary has worked as a gynecological cancer nurse for 16 years. For the past 12
years she has worked as the clinical nurse consultant for the Gynaecological Cancer
Centre at the Royal Hospital for Women (Sydney, Australia). Mary combines her
role of managing the chemotherapy program in the gynecological cancer centre with
researching the effects on women of gynecological cancer and its treatment. With her
colleagues, she has recently published papers on the prevalence and effects of lower-
limb lymphedema following gynecological cancer treatment. Mary has presented the
results of her research at local, national, and international conferences.

Anne Sargent
Chapter 16
Anne Sargent is a registered nurse who holds a certificate in advanced nursing practice
in continence management from Flinders University (South Australia). She is president
of the Continence Foundation of Australia in New South Wales (NSW) and a member
xxii
About the Authors

of the Australian Nurses for Continence, the Association of Nurse Continence Advisers
(NSW), and the Australasian Urological Nurses Society. Anne has had more than 30
years of nursing experience in Australia, Scotland, America, and Canada. She has
worked in her current position as a clinical nurse consultant for continence care in the
Penrith, Blue Mountains, and Hawkesbury areas of NSW for the past nine years.

Sheila Slater
Chapter 2
Sheila Slater is a registered mental nurse and registered general nurse. She has a
bachelor’s degree in science (hons) in health psychology, and holds qualifications
in counselling. Sheila is currently undertaking a postgraduate diploma in genetic
counselling. She has interests in the psychology and ethics of clinical genetics, and
is a lecturer in genetics and cancer genetics at Queen Margaret University College
(Edinburgh, Scotland). Sheila was the coordinator for a recent national study looking at
the role played by genes in the development of endometrial cancer in women diagnosed
under the age of 55 years.

Katharine Smith
Chapter 17
Katharine Smith is a clinical psychologist who holds a master’s degree in clinical
psychology. She is a member of the Australian Psychological Society’s College of
Clinical Psychologists and the Clinical Oncological Society of Australia. Katharine has
been working at the Westmead Centre for Gynaecological Cancer (Sydney, Australia)
for more than seven years. She is currently a PhD candidate at the University of
Sydney. Katharine’s research explores predictors of psychosocial outcomes and unmet
supportive care needs in cancer survivors and their partners. She has developed two
new research tools to assess unmet needs in cancer survivors and their partners.
Katharine’s clinical interests include the assessment of sexual difficulties, and she
has been involved in the promotion of communication strategies and interventions for
healthcare professionals who address sexuality in the healthcare setting.

Margaret Sneddon
Chapter 14
Margaret Sneddon is a registered nurse and midwife, and a recorded clinical nurse
teacher. She holds a master of science research degree—which focused on the outcome
of palliative-care education on practice. She also holds a postgraduate certificate in
teaching and learning in higher education. Margaret worked as a nurse in gynecology
in Scotland for six years before becoming the first gynecology cancer specialist nurse
in the UK. After training as a clinical nurse teacher, Margaret took up a joint clinical,
education, and research post in palliative care. The clinical aspect of the post involved
setting up a palliative-care support team in an acute hospital. The research was the
basis of her master’s degree. As a consequence of the research she was employed to
 xxiii
About the Authors

establish and then direct Scotland’s first multiprofessional program in palliative care in
the University of Glasgow. Margaret is now responsible for the cancer branch of the
master of science in health care at the University of Glasgow. Having run lymphedema
courses since 1996, she also directs the program for the graduate diploma in chronic
edema management. She is a teacher of the Casley-Smith method of manual lymphatic
drainage. Margaret is actively involved with the British Lymphology Society, of which
she is currently vice chairperson.

Catherine Spencer
Chapter 5
Catherine Spencer is a registered nurse with post-registration qualifications in oncology
and gynecological oncology. She also holds a bachelor’s degree in science (nursing).
Her dissertation researched the experiences of women undergoing radical trachelectomy
for early-stage cancer of the cervix. Catherine has worked in the field of gynecological
cancer for 13 years at St Bartholomew’s Hospital and the Royal Marsden Hospital
(both London, UK). She is the Macmillan clinical nurse specialist in gynecological
oncology at St Bartholomew’s Hospital and leads a team of gynecological oncology
specialist nurses for the North-East London Cancer Network. She also teaches at City
University (London) on postgraduate courses in oncology and gynecological oncology.
Catherine’s publications include articles on nursing management of malignant fistulas,
fertility-sparing surgery for women with cervical cancer, and fertility options in ovarian
cancer. She is an active member (and former council member) of the National Forum of
Gynaecological Oncology Nurses. Catherine represents nursing on the trachelectomy
subgroup of the British Gynaecological Cancer Society.

Annie Stenlake
Chapter 3
Annie Stenlake is a registered nurse who holds an emergency-nursing certificate and
a bachelor’s degree in health-service management (information). She is an associate
fellow of the Australian College of Health Service Executives. Annie has worked in
various capacities in the health sector, including five years as an emergency-care nurse
at Royal Prince Alfred Hospital (Sydney, Australia); ten years in the private sector
in clinical nursing and quality management, and two years as standards-development
project officer with the Australian Council on Healthcare Standards. For most of the
past ten years Annie has held her current position as the data manager/clinical trial
coordinator for the Department of Gynaecological Oncology at Westmead Hospital in
Sydney. During that time, she spent two years as project officer with the NSW Cervical
Screening Program working on developing strategies to improve screening in the
general-practice setting. Since joining the Gynaecological Oncology Unit at Westmead,
Annie has been responsible for coordinating the development and review of the clinical-
practice guidelines for the Gynaecological Oncology Study Group. She currently sits
on the Research Advisory Committee for the Australia New Zealand Gynaecological
Oncology Group.
xxiv
About the Authors

Diane Stirling
Chapter 2
Diane Stirling is a registered general nurse and registered genetic counsellor. She holds
a bachelor’s degree in science (nursing studies in genetics) and a specialist practitioner
qualification in genetics. Diane has worked as a Macmillan clinical nurse specialist in
the field of genetics for the past ten years within the South East of Scotland Clinical
Genetics Services. Diane has provided nursing representation on a variety of national
working parties. As a member of the Scottish Intercollegiate Guidelines Network—
Epithelial Ovarian Cancer Group, she was involved in the development of evidence-
based guidelines in the management of this disease, and as a member of the UK
Association of Genetic Nurses and Counsellors Education Working Group, she was
involved in the development of a registration process for genetic counsellors. Diane
now functions as an assessor within this process, and also coordinates a cancer genetics
course at Queen Margaret University College (Edinburgh, Scotland).

Julia Thompson
Chapter 15
Julia Thompson is a registered nurse who holds post-basic certificates in cardiothoracic
and stomal therapy nursing, a diploma in nurse education, a bachelor of arts degree
(psychology), a graduate certificate in advanced clinical nursing, and a PhD. Her doctoral
treatise focused on patient and nurse collaboration in long-term management of newly
formed colostomies. Since 1978 most of Julia’s work has been in stomal therapy as a
clinical nurse consultant and senior lecturer. She is now the clinical nurse consultant in
stomal therapy and palliative care at St Vincents Private Hospital (Sydney, Australia).
Julia is a fellow of the College of Nursing. She is a member of editorial boards for
the Journal o f Stomal Therapy Australia and the Journal o f the World Council o f
Enterostomal Therapists fWCET). Julia was honorary editor of the WCET Journal and
an executive board member of WCET for six years. She is a writer, marker, and tutor
for the distance-education graduate certificate in stomal therapy nursing run by the
College of Nursing. Julia has published more than 40 papers and authored six patient-
education booklets and several videotapes. She has spoken at more than 50 national and
international conferences and frequently organizes seminars on stomal therapy.

Ellen Toms
Chapter 10
Ellen Toms is a registered nurse who holds a diploma in professional studies (nursing),
a bachelor’s degree in cancer nursing (with honours), and a master’s degree in advanced
clinical practice cancer nursing. Her formative nursing years were spent in general
gynecology while completing her diploma in professional studies. She then moved
to the gynecological oncology ward at the Royal Marsden Hospital (London, UK),
followed by a ward manager’s position in a 50-bed gynecology unit. Ellen then helped
to set up the gynecological oncology ward and service at Portsmouth Hospital (UK),
 XXV
About the Authors

before moving to a clinical nurse specialist post in Portsmouth in 1999. Ellen now works
in Guildford (UK) as a network clinical nurse specialist. Her main interests are service
and strategic development, national standards, research, and education. She is currently
the president o f the UK National Forum of Gynaecological Oncology Nurses.

Karima Velji
Chapter 11
Karima Velji is a registered nurse with a master’s degree in nursing. She is an advanced
oncology certified nurse (AOCN) and a PhD candidate in the Faculty of Nursing at
the University of Toronto (Canada). Karima is vice-president of professional practice
and chief nursing executive of Toronto Rehab— Canada’s largest academic hospital
specializing in adult rehabilitation and complex continuing care. She has cross
appointments to the Faculties o f Nursing at the University of Toronto and to McMaster
University. Karima’s funded research programs focus on symptom management and
quality of life in cancer. Her research training has focused on clinical trials and evaluation
of individualized educational interventions for management of cancer symptoms. She
is currently developing and testing evidence-based support and education interventions
during radiation therapy for gynecological cancers.
Female pelvic organs; antero-posterior view
© T ish La n c a s t e r and K athryn N attress ; a d a p t e d from a d r a w in g by L in d a F orss
Female pelvic organs; lateral view
© T ish La n c a s t e r and K athryn N attress ; a d a p t e d from a d r a w in g by L in d a Forss
 Chapter I
Setting the Scene
Tish Lancaster

Introduction
The term ‘gynaecological cancer’ refers to a disparate group of malignancies
of a woman’s reproductive organs. These malignancies differ in their risk
factors, clinical features, management, and prognosis. Worldwide they account
for approximately 18% of all female cancers, making them the second most
common cancer in women (after breast
cancer) (Ferlay et al. 2004). Collectively,
gynaecological cancers represent the most ‘Collectively, gynaecological
common cause of cancer death in women— cancers represent the
accounting for nearly 15% of all female most common cause o f
cancer deaths (Ferlay et al. 2004). cancer death in women—
accountingfo r nearly 15%
A diagnosis of gynaecological cancer
o f all female cancer deaths. ’
usually produces shock, anxiety, disbelief,
and confusion for a woman and those close
to her. The diagnosis presents many challenges—including the challenge of
dealing with a life-threatening illness, concern about alteration in body image
and sexual functioning, and alterations in roles within the woman’s family and
social milieu. Gynaecological cancer affects a woman’s relationships, sense
of femininity, and fertility. For some women the diagnosis might engender
feelings of guilt or isolation. For others, it can cause them to question past
sexual and health behaviour.
Gynaecological Cancer Care

Framework of the chapter

This chapter‘sets the scene’ by discussing gynaecological cancer in general
under the following headings:
• Incidence and mortality (this page)
• Ovarian cancer (page 4)
• Cervical cancer (page 5)
• U terine cancer (page 7)
• Vulval cancer (page 9)
• Vaginal cancer (page 10)
• Gestational trophoblastic disease (page 11)

Cancer is a disease of ageing. The disease has often been present for
some time before it produces signs or symptoms that allow it to be detected.
Between 1975 and 2000 there was a 69% increase in the worldwide incidence
of cancer (Wilson, Tobin & Young 2004). This trend is expected to continue
as the global population increases and ages. Lifestyle factors—such as
smoking, physical inactivity, and certain diets—play a role in the initiation
and increasing incidence of some cancers.
In developed countries, prevention and screening programs have made
a significant contribution to a decline in the incidence (and the mortality) of
certain cancers. In developing countries, infectious diseases (such as malaria,
tuberculosis, and AIDS) are of greater significance than cancer in terms of
incidence and mortality. However, as preventive programs and treatments for
these diseases become more accessible, and as populations begin to adopt
certain aspects of Western lifestyles, the burden of cancer in developing
countries is likely to increase.

Incidence and mortality

Although gynaecological cancer occurs in all areas of the world, there are
regional differences in incidence (see Table 1.1, page 3) and mortality (see
Table 1.2, page 3). These differences are likely to be related to lifestyle and
socioeconomic factors.
 3
Setting the Scene

Table 1.1 Worldwide incidence rates for most common cancers in

women
A u t h o r ’s presen ta tio n a d a p t e d fro m F erlay et a l . (2 0 0 4 )

Ovary Cervix Uterus Breast Bowel Lung Stomach

World 6.6 16.2 6.5 37.4 14.6 12.0 10.4

Developed countries 10.2 10.3 13.6 67.8 26.6 17.1 10.0

Developing countries 5.0 19.1 3.0 23.8 7.7 9.4 10.4

Australia and New Zealand 9.4 7.4 10.6 84.6 36.9 17.4 4.5

South-East Asia 7.2 18.7 4.2 25.5 9.9 8.9 4.5

United Kingdom 13.4 8.0 11.0 87.2 26.5 24.9 5.5

Western Europe 11.3 10.0 12.5 84.6 29.8 12.0 6.6

North America 10.7 7.7 22.0 99.4 32.9 35.6 3.4
South America 7.7 28.6 6.7 46.0 14.8 7.6 12.2

Southern Africa 5.2 38.2 3.5 33.4 9.0 6.9 3.7

Age standardised rate per 100,000 population

Table 1.2 Worldwide mortality rates for most common cancers in

women
A u t h o r ’ s presen ta tio n a d a p t e d fro m F erlay et a l . (2 0 0 4 )

Ovary Cervix Uterus Breast Bowel Lung Stomach

World 4.1 9.0 1.6 13.2 7.6 10.3 7.9
Developed countries 5.7 4.0 2.5 18.1 12.3 13.6 6.9
Developing countries 2.9 1l.l 1.0 10.3 4.7 8.6 8.3
Australia and New Zealand 5.1 2.0 1.7 19.4 14.1 14.6 4.1
South-East Asia 4.1 10.2 1.6 11.8 6.2 8.3 3.9
U n ite d K in g d o m 8.0 3.1 1.8 24.3 12.4 21.1 4.0
Western Europe 6.3 3.4 2.1 22.3 14.0 10.3 5.9
North America 6.1 2.3 2.6 19.2 11.6 26.7 2.2
South America 3.7 12.9 2.0 15.1 7.4 7.5 9.3
Southern Africa 3.2 22.6 1.5 16.3 6.0 6.3 3.2

Age standardised rate per 100,000 population

4
Gynaecological Cancer Care

For each cancer, the relationship between incidence and mortality

is indicative of prognosis (Stewart & Kleihues 2003). For example, the
worldwide incidence of ovarian cancer is 6.6 (per 100,000 of population) and
the mortality is 4.1—meaning that almost two-thirds of women diagnosed
with ovarian cancer will die of their disease. In contrast, the worldwide
incidence of uterine cancer is 6.5 (per 100,000), but the mortality is only
1.6—indicating a better prognosis with only about one-quarter of women
diagnosed with uterine cancer dying of the disease.

Ovarian cancer
Ovarian cancer originates from various types of cells in the ovary. The most
common type arises from the epithelial surface of the ovary, whereas rarer
forms of ovarian cancer arise from the germ cells and the sex cord-stromal
cells.

Epithelial ovarian cancer

In this book, the term ‘ovarian cancer’ refers to epithelial ovarian cancer,
which accounts for about 90% of all ovarian cancers (ACN 2004). Ovarian
cancer occurs predominantly in women who live in developed countries,
where it is the second most common
‘Ovarian cancer is tie 8ynaecoi°* ic?! f li8nanc>' a”d leading
r . cause of death from gynaecological cancer
second most common _ , t f
r r r
aynaecoLoaical malianancy
(Ferlay et al. 2004). The high mortality rate
\ J ,
• r r x
in developed countries, anas ,
for women with ovarian cancer is attributed
, , 11 ,
r
r /
the leadina cause ofr death
r r
s c
>
to the lack of a reliable screening test and
the absence of specific symptoms until the
f
from gynaecological cancer.
J
^
disease is well established. Of all women
„
diagnosed with ovarian cancer, 85% already
have advanced disease, and 80% of women with ovarian cancer die within
five years of diagnosis (Paley 2001; Tingulstad et al. 2003).
Epithelial ovarian cancer occurs most commonly in women over
the age of 50 years. Most women have no identifiable risk factors for the
development of ovarian cancer, although 5-10% of diagnosed women have
a genetic predisposition to the disease (Stewart & Kleihues 2003). Familial
ovarian cancer syndromes are related to mutations in specific genes (see
Chapter 2, ‘Genetic Susceptibility’, page 13).
 5
Setting the Scene

The inability of the epithelial surface of the ovary to repair itself

repeatedly after ovulation is believed to play a part in the development of
ovarian cancer. Repair of the ovarian surface becomes less efficient with
advancing age. Factors that decrease the total number of ovulatory cycles
are therefore thought to confer some protection against the development
of ovarian cancer. These factors include irregular menstrual cycles, the use
of oral contraceptives, breastfeeding, and a greater number of pregnancies
(Riman et al. 2002).
Possible links between ovarian cancer and the use of fertility drugs or
perineal talc are still being debated (La Vecchia 2003; Cramer et al. 1999;
Wong et al. 1999).

Uncommon ovarian cancers

Germ cell tumours make up a rare group of cancers that occur most commonly
in young women, usually in their teens and twenties. Women with germ cell
tumours account for 2-3% of all women with ovarian cancer, except among
Asian and black women in whom they account for approximately 15% (Ozols,
Schwartz & Eifel 2001). Of all women with germ cell tumours, 60-70% are
diagnosed with early-stage disease (Tresukosol & Fox 1999). With prompt
and appropriate treatment, the cure rate is high.
Approximately 5% of women with ovarian cancer have sex cord-
stromal tumours (Ozols, Schwartz & Eifel 2001). These are slow-growing
tumours that can occur at any age (including before puberty); however, 40%
of women are post-menopausal (Tresukosol & Fox 1999). Most women tend
to have early-stage disease at diagnosis. Prognosis is directly related to the
stage at diagnosis, and women presenting with advanced disease have a poor
prognosis.

Cervical cancer
Cervical cancer is the second most common cancer in women worldwide,
and is the leading cause of cancer deaths in women in developing countries
(Ferlay et al. 2004). It is the most preventable gynaecological cancer because
a precursor lesion is readily identifiable several years before the development
of invasive cancer. Moreover, there are effective and reliable screening tools
for the detection of these pre-invasive cervical abnormalities.
6
Gynaecological Cancer Care

Types of gynaecological cancer

This portion of the te x t provides an overview of the various types o f
gynaecological cancer. The following cancers are noted.

Ovarian cancer
• Epithelial ovarian cancer
• Uncommon ovarian cancers

Cervical cancer

Uterine cancer
• Endometrial cancer
• U terine sarcomas

Vulval cancer
• General
• Rare vulval cancers

Vaginal cancer
• General
• Rare vaginal cancers

Gestational trophoblastic disease

In developed countries, almost 90% of women with early-stage cervical

cancer are cured of their disease (Feldman 2003). Women who present with
advanced cancer have usually never been screened—and their prognosis is
less favourable.
Across all populations, women at greatest risk of developing cervical
cancer are over the age of 50 years, illiterate, and of low socioeconomic status
(ISNCC 2001). In developed countries, migrant and indigenous women are at
greatest risk—because most have never been screened.
Human papilloma virus (HPV) is the major cause of cervical cancer.
This virus is present in almost all women with cervical cancer (Stewart &
Kleihues 2003). HPV is the most common sexually transmitted infection,
with transmission occurring during any form of sexual skin-to-skin contact
(McDermott-Webster 1999).
 7
Setting the Scene

Other important factors that increase the risk of women developing

cervical cancer include cigarette smoking, early age at first intercourse, and
multiple sexual partners. Women with compromised immune systems—such
as those who take immunosuppressant drugs after organ transplantation,
or those with HIV infection—are also at risk. Invasive cervical cancer is
regarded as an AIDS-defining illness in HIV-positive women (Ellerbrock et
al. 2000).

Uterine cancer
Uterine cancer is the most common gynaecological cancer in developed
countries, accounting for nearly 40% of all gynaecological cancers in these
countries (Ferlay et al. 2004). Approximately 90% of women with uterine
cancer have an epithelial cancer arising in the endometrium (lining of the
uterus). The remaining 10% have sarcoma, usually arising in the body of the
uterus (Burke, Eifel & Muggia 2001).
Endometrial cancer and uterine sarcomas are both more prevalent in
post-menopausal women over the age of 60 years. About 5% of women with
uterine cancer are diagnosed before the age of 40 years (Stewart & Kleihues
2003).

Endometrial cancer
Of all women diagnosed with endometrial cancer, 75% are in the early stages,
and most are cured of their disease (Barakat 1998). The low mortality rate is
attributed to the fact that symptoms develop early in the course of the disease.
Advanced disease at diagnosis is usually due to symptoms having been
overlooked.
The strongest risk factor for the development of endometrial cancer
is chronically high levels of circulating oestrogen. Oestrogen promotes
growth and proliferation of the endometrium, which is normally regulated by
progesterone.
Several factors can contribute to high circulating oestrogen. These
include:
• obesity—obese women have higher levels of circulating oestrogen
because an androgen hormone (androstenedione) is converted to an
oestrogen hormone (oestrone) in body fat (Porter 2002);
• polycystic ovary syndrome—this condition is also associated with
increased circulating oestrogen; and
8
Gynaecological Cancer Care

• certain forms o f hormone replacement therapy—women taking

oestrogen as hormone replacement therapy for the management of
menopausal symptoms are at increased risk unless the oestrogen is
balanced by the use of progesterone.
Reproductive factors that increase circulating oestrogen levels include
infrequent ovulation, young age at onset of menstruation, older age at
menopause, and never having been pregnant (because pregnancy is associated
with high levels of progesterone).

Risk factors for endometrial cancer

This portion of the te x t discusses risk factors for endometrial cancer.
The most im portant risk factor is chronically high levels of circulating
oestrogen. As discussed m ore fully in the text, the following are risk
factors for endometrial cancer:
• obesity;
• polycystic ovary syndrome;
• certain forms of hormone replacement therapy;
• infrequent ovulation;
• young age at onset of menstruation;
• older age at menopause;
• never having been pregnant;
• diabetes;
• hypertension;
• tamoxifen therapy; and
• genetic predisposition.

Women with diabetes and hypertension are at increased risk of the

development of endometrial cancer. The reason for this is unclear, but both
diabetes and hypertension are associated with obesity.
Women who take tamoxifen to reduce their risk of recurrence of breast
cancer are also at risk of developing endometrial cancer. Although tamoxifen
is prescribed for its anti-oestrogen effect in the breast, it is also understood to
have some oestrogen-promoting effects in the endometrium (Burke, Eifel &
Muggia 2001).
 9
Setting the Scene

A small number of women with endometrial cancer have a genetic

predisposition to its development. These women have a significantly
increased risk of developing endometrial cancer and commonly develop it at
a younger age (Frank & Critchfield 2002).
Medium-to-long-term use of combined oestrogen and progesterone oral
contraceptives has a protective effect against endometrial cancer because it
reduces endometrial proliferation.

Uterine sarcomas
Uterine sarcomas are uncommon and aggressive cancers. Apart from those
with early-stage disease, most women tend to respond poorly to treatment, and
most die within 1-2 years of diagnosis (Crowder & Santoso 2001). Women
who have had prior radiotherapy to the pelvis or who have used tamoxifen
have an increased risk of developing uterine sarcoma (O’Meara 2004).

Vulval cancer
General
Vulval cancer is an uncommon cancer, accounting for approximately 3-8% of
all gynaecological cancers and 1% of all cancers in women (Hall 2002). Up
to 90% of women with early stage vulval cancer are cured (Creasman, Phillip
& Menck 1997). Women with a poorer prognosis tend to be of an older age
and have more advanced disease at diagnosis.
Vulval cancer occurs predominantly in women over the age of 70
years; however, up to 15% of women are under the age of 40 years (Crowder,
Coleman & Santoso 2001). An increasing incidence in younger women has
been attributed to smoking and infection with HPV (Spinelli 2002).
Vulval cancer can be attributed to HPV in 30% of women (Stewart
& Kleihues 2003). Another risk factor is a long history of vulval irritation.
Such irritation is more common in women with diabetes, obesity, and chronic
inflammatory processes (such as lichen sclerosis). Women with compromised
immune systems are also at risk.

Rare vulval cancers

Rare vulval cancers include sarcomas, lymphomas, and melanoma. Melanoma
is the most common, accounting for 2—4% of vulval cancers and 2-3% of all
melanomas in women (Eifel, Berek & Thigpen 2001). Unlike melanoma in
10
Gynaecological Cancer Care

most other areas of the body, the development of gynaecological melanoma

is unrelated to sun exposure. Approximately 60% of women with vulval
melanoma are cured (Hall 2002). Women who are older or have unpigmented
(amelanotic), ulcerated, or deeply invading lesions have a poorer prognosis
(Eifel, Berek & Thigpen 2001).

Vaginal cancer
General
Vaginal cancer is uncommon, representing 1-2% of all gynaecological
cancers (Lee & Santoso 2001). Although vaginal cancer can occur in women
of any age, it occurs most commonly in women aged more than 60 years.
Nearly three-quarters of women presenting with early-stage vaginal cancer
and just over half the women with more advanced cancer survive their disease
(Creasman, Phillip & Menck 1998).
HPV is the causative factor in 30% of women with vaginal cancer
(Stewart & Kleihues 2003). HPV is transmitted via vaginal abrasions
associated with trauma such as intercourse and tampon use. Chronic irritation
from prolonged use of vaginal pessaries might be a contributing factor in the
development of vaginal cancer (Eifel, Berek & Thigpen 2001).

Rare vaginal cancers

Rare vaginal cancers include adenocarcinoma and melanoma. Adenocarcinoma
accounts for about 9% of vaginal cancers and tends to occur in younger
women (Hacker 2000). Maternal use of the drug diethylstilbestrol (DES)
during pregnancy has been associated with the development of clear cell
adenocarcinoma of the vagina in the daughters of women who took this
drug. DES was extensively prescribed for pregnant women in the 1950s and
1960s to prevent miscarriage and premature birth. Most women diagnosed
with clear cell vaginal cancer related to DES exposure present with early-
stage disease and are young, with a peak age at diagnosis of 19 years (Hacker
2000). However, intrauterine exposure to DES rarely leads to vaginal cancer,
and the risk of clear cell vaginal cancer in DES daughters is only 1 in 1000
(Herbst 1999).
Vaginal melanoma is extremely rare, accounting for 3% of vaginal
cancers and fewer than 0.3% of all melanomas in women (Miner et al. 2004).
It develops in melanocytes, which are present in the vaginal mucosa of a very
 II
Setting the Scene

small number of women. Vaginal melanoma is regarded as an aggressive

cancer. Affected women have an extremely poor prognosis. Approximately
65% die within two years of diagnosis (Buchanan, Schlaerth & Kurosaki
1998).

Gestational trophoblastic disease

Gestational trophoblastic disease (GTD) is a pregnancy-related condition
characterised by abnormal growth of placental tissue. It encompasses a
spectrum of diseases ranging from benign to malignant. Malignant GTD
accounts for fewer than 1% of gynaecological cancers (Muggia, Eiffel &
Burke 2001). Although it can be life-threatening, with appropriate treatment
women have a good chance of cure.
The incidence of GTD varies widely throughout the world—ranging
from 1 in 77 pregnancies in Indonesia to 1 in 1200 pregnancies in developed
countries (Smith 2003; Muggia, Eiffel & Burke 2001). The risk of GTD
is greater in teenagers, in women over the age of 40 years, and in women
with a history of GTD. Other reproductive factors—such as a history of
irregular menstrual periods and the use of oral contraceptives for more than
four years—might also contribute to the development of GTD (Berkowitz &
Goldstein 1996). Factors such as ethnicity, number of pregnancies, nutritional
factors, and cigarette smoking have been proposed, but have not been
confirmed as risk factors (Smith 2003).

Conclusion
Health professionals who care for women with gynaecological cancer face a
variety of challenges. Diverse needs must be addressed.
Gynaecological cancer is not a single disease.
Rather, gynaecological cancers represent a disparate ‘CjynaecoCogicaC
group of diseases with widely differing clinical cancers represent a
features, patterns of management, and survival disparate group o f
rates. Moreover, the incidence and mortality of diseases with wideCy
these diseases differ in various parts of the world. differingfeatures. ’
In addition to diversity in the diseases
themselves, the distinctive personal circumstances of each individual
woman must be taken into account. Although common general themes are
apparent—particularly in the impact of such a diagnosis on the woman and
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word ὥρα received the (Babylonian) significance of “hour”; prior to
that there was no exact subdivision of the day. In Babylon and Egypt
water-clocks and sun-dials were discovered in the very early stages,
yet in Athens it was left to Plato to introduce a practically useful form
of clepsydra, and this was merely a minor adjunct of everyday utility
which could not have influenced the Classical life-feeling in the
smallest degree.
It remains still to mention the corresponding difference, which is
very deep and has never yet been properly appreciated, between
Classical and modern mathematics. The former conceived of things
as they are, as magnitudes, timeless and purely present, and so it
proceeded to Euclidean geometry and mathematical statics,
rounding off its intellectual system with the theory of conic sections.
We conceive things as they become and behave, as function, and
this brought us to dynamics, analytical geometry and thence to the
Differential Calculus.[9] The modern theory of functions is the
imposing marshalling of this whole mass of thought. It is a bizarre,
but nevertheless psychologically exact, fact that the physics of the
Greeks—being statics and not dynamics—neither knew the use nor
felt the absence of the time-element, whereas we on the other hand
work in thousandths of a second. The one and only evolution-idea
that is timeless, ahistoric, is Aristotle’s entelechy.
This, then, is our task. We men of the Western Culture are, with
our historical sense, an exception and not a rule. World-history is our
world picture and not all mankind’s. Indian and Classical man formed
no image of a world in progress, and perhaps when in due course
the civilization of the West is extinguished, there will never again be
a Culture and a human type in which “world-history” is so potent a
form of the waking consciousness.
 VI
What, then, is world-history? Certainly, an ordered presentation of
the past, an inner postulate, the expression of a capacity for feeling
form. But a feeling for form, however definite, is not the same as
form itself. No doubt we feel world-history, experience it, and believe
that it is to be read just as a map is read. But, even to-day, it is only
forms of it that we know and not the form of it, which is the mirror-
image of our own inner life.
Everyone of course, if asked, would say that he saw the inward
form of History quite clearly and definitely. The illusion subsists
because no one has seriously reflected on it, still less conceived
doubts as to his own knowledge, for no one has the slightest notion
how wide a field for doubt there is. In fact, the lay-out of world-history
is an unproved and subjective notion that has been handed down
from generation to generation (not only of laymen but of professional
historians) and stands badly in need of a little of that scepticism
which from Galileo onward has regulated and deepened our inborn
ideas of nature.
Thanks to the subdivision of history into “Ancient,” “Mediæval” and
“Modern”—an incredibly jejune and meaningless scheme, which has,
however, entirely dominated our historical thinking—we have failed
to perceive the true position in the general history of higher mankind,
of the little part-world which has developed on West-European[10] soil
from the time of the German-Roman Empire, to judge of its relative
importance and above all to estimate its direction. The Cultures that
are to come will find it difficult to believe that the validity of such a
scheme with its simple rectilinear progression and its meaningless
proportions, becoming more and more preposterous with each
century, incapable of bringing into itself the new fields of history as
they successively come into the light of our knowledge, was, in spite
of all, never whole-heartedly attacked. The criticisms that it has long
been the fashion of historical researchers to level at the scheme
mean nothing; they have only obliterated the one existing plan
without substituting for it any other. To toy with phrases such as “the
Greek Middle Ages” or “Germanic antiquity” does not in the least
help us to form a clear and inwardly-convincing picture in which
China and Mexico, the empire of Axum and that of the Sassanids
have their proper places. And the expedient of shifting the initial
point of “modern history” from the Crusades to the Renaissance, or
from the Renaissance to the beginning of the 19th Century, only
goes to show that the scheme per se is regarded as unshakably
sound.
It is not only that the scheme circumscribes the area of history.
What is worse, it rigs the stage. The ground of West Europe is
treated as a steady pole, a unique patch chosen on the surface of
the sphere for no better reason, it seems, than because we live on it
—and great histories of millennial duration and mighty far-away
Cultures are made to revolve around this pole in all modesty. It is a
quaintly conceived system of sun and planets! We select a single bit
of ground as the natural centre of the historical system, and make it
the central sun. From it all the events of history receive their real
light, from it their importance is judged in perspective. But it is in our
own West-European conceit alone that this phantom “world-history,”
which a breath of scepticism would dissipate, is acted out.
We have to thank that conceit for the immense optical illusion
(become natural from long habit) whereby distant histories of
thousands of years, such as those of China and Egypt, are made to
shrink to the dimensions of mere episodes while in the
neighbourhood of our own position the decades since Luther, and
particularly since Napoleon, loom large as Brocken-spectres. We
know quite well that the slowness with which a high cloud or a
railway train in the distance seems to move is only apparent, yet we
believe that the tempo of all early Indian, Babylonian or Egyptian
history was really slower than that of our own recent past. And we
think of them as less substantial, more damped-down, more diluted,
because we have not learned to make the allowance for (inward and
outward) distances.
It is self-evident that for the Cultures of the West the existence of
Athens, Florence or Paris is more important than that of Lo-Yang or
Pataliputra. But is it permissible to found a scheme of world-history
on estimates of such a sort? If so, then the Chinese historian is quite
entitled to frame a world-history in which the Crusades, the
Renaissance, Cæsar and Frederick the Great are passed over in
silence as insignificant. How, from the morphological point of view,
should our 18th Century be more important than any other of the
sixty centuries that preceded it? Is it not ridiculous to oppose a
“modern” history of a few centuries, and that history to all intents
localized in West Europe, to an “ancient” history which covers as
many millennia—incidentally dumping into that “ancient history” the
whole mass of the pre-Hellenic cultures, unprobed and unordered,
as mere appendix-matter? This is no exaggeration. Do we not, for
the sake of keeping the hoary scheme, dispose of Egypt and
Babylon—each as an individual and self-contained history quite
equal in the balance to our so-called “world-history” from
Charlemagne to the World-War and well beyond it—as a prelude to
classical history? Do we not relegate the vast complexes of Indian
and Chinese culture to foot-notes, with a gesture of embarrassment?
As for the great American cultures, do we not, on the ground that
they do not “fit in” (with what?), entirely ignore them?
The most appropriate designation for this current West-European
scheme of history, in which the great Cultures are made to follow
orbits round us as the presumed centre of all world-happenings, is
the Ptolemaic system of history. The system that is put forward in
this work in place of it I regard as the Copernican discovery in the
historical sphere, in that it admits no sort of privileged position to the
Classical or the Western Culture as against the Cultures of India,
Babylon, China, Egypt, the Arabs, Mexico—separate worlds of
dynamic being which in point of mass count for just as much in the
general picture of history as the Classical, while frequently
surpassing it in point of spiritual greatness and soaring power.
 VII
The scheme “ancient-mediæval-modern” in its first form was a
creation of the Magian world-sense. It first appeared in the Persian
and Jewish religions after Cyrus,[11] received an apocalyptic sense in
the teaching of the Book of Daniel on the four world-eras, and was
developed into a world-history in the post-Christian religions of the
East, notably the Gnostic systems.[12]
This important conception, within the very narrow limits which fixed
its intellectual basis, was unimpeachable. Neither Indian nor even
Egyptian history was included in the scope of the proposition. For the
Magian thinker the expression “world-history” meant a unique and
supremely dramatic act, having as its theatre the lands between
Hellas and Persia, in which the strictly dualistic world-sense of the
East expressed itself not by means of polar conceptions like the
“soul and spirit,” “good and evil” of contemporary metaphysics, but
by the figure of a catastrophe, an epochal change of phase between
world-creation and world-decay.[13]
No elements beyond those which we find stabilized in the
Classical literature, on the one hand, and the Bible (or other sacred
book of the particular system), on the other, came into the picture,
which presents (as “The Old” and “The New,” respectively) the
easily-grasped contrasts of Gentile and Jewish, Christian and
Heathen, Classical and Oriental, idol and dogma, nature and spirit
with a time connotation—that is, as a drama in which the one
prevails over the other. The historical change of period wears the
characteristic dress of the religious “Redemption.” This “world-
history” in short was a conception narrow and provincial, but within
its limits logical and complete. Necessarily, therefore, it was specific
to this region and this humanity, and incapable of any natural
extension.
But to these two there has been added a third epoch, the epoch
that we call “modern,” on Western soil, and it is this that for the first
time gives the picture of history the look of a progression. The
oriental picture was at rest. It presented a self-contained antithesis,
with equilibrium as its outcome and a unique divine act as its turning-
point. But, adopted and assumed by a wholly new type of mankind, it
was quickly transformed (without anyone’s noticing the oddity of the
change) into a conception of a linear progress: from Homer or Adam
—the modern can substitute for these names the Indo-German, Old
Stone Man, or the Pithecanthropus—through Jerusalem, Rome,
Florence and Paris according to the taste of the individual historian,
thinker or artist, who has unlimited freedom in the interpretation of
the three-part scheme.
This third term, “modern times,” which in form asserts that it is the
last and conclusive term of the series, has in fact, ever since the
Crusades, been stretched and stretched again to the elastic limit at
which it will bear no more.[14] It was at least implied if not stated in so
many words, that here, beyond the ancient and the mediæval,
something definitive was beginning, a Third Kingdom in which,
somewhere, there was to be fulfilment and culmination, and which
had an objective point.
As to what this objective point is, each thinker, from Schoolman to
present-day Socialist, backs his own peculiar discovery. Such a view
into the course of things may be both easy and flattering to the
patentee, but in fact he has simply taken the spirit of the West, as
reflected in his own brain, for the meaning of the world. So it is that
great thinkers, making a metaphysical virtue of intellectual necessity,
have not only accepted without serious investigation the scheme of
history agreed “by common consent” but have made of it the basis of
their philosophies and dragged in God as author of this or that
“world-plan.” Evidently the mystic number three applied to the world-
ages has something highly seductive for the metaphysician’s taste.
History was described by Herder as the education of the human
race, by Kant as an evolution of the idea of freedom, by Hegel as a
self-expansion of the world-spirit, by others in other terms, but as
regards its ground-plan everyone was quite satisfied when he had
thought out some abstract meaning for the conventional threefold
order.
On the very threshold of the Western Culture we meet the great
Joachim of Floris (c. 1145-1202),[15] the first thinker of the Hegelian
stamp who shattered the dualistic world-form of Augustine, and with
his essentially Gothic intellect stated the new Christianity of his time
in the form of a third term to the religions of the Old and the New
Testaments, expressing them respectively as the Age of the Father,
the Age of the Son and the Age of the Holy Ghost. His teaching
moved the best of the Franciscans and the Dominicans, Dante,
Thomas Aquinas, in their inmost souls and awakened a world-
outlook which slowly but surely took entire possession of the
historical sense of our Culture. Lessing—who often designated his
own period, with reference to the Classical as the “after-world”[16]
(Nachwelt)—took his idea of the “education of the human race” with
its three stages of child, youth and man, from the teaching of the
Fourteenth Century mystics. Ibsen treats it with thoroughness in his
Emperor and Galilean (1873), in which he directly presents the
Gnostic world-conception through the figure of the wizard Maximus,
and advances not a step beyond it in his famous Stockholm address
of 1887. It would appear, then, that the Western consciousness feels
itself urged to predicate a sort of finality inherent in its own
appearance.
But the creation of the Abbot of Floris was a mystical glance into
the secrets of the divine world-order. It was bound to lose all
meaning as soon as it was used in the way of reasoning and made a
hypothesis of scientific thinking, as it has been—ever more and more
frequently—since the 17th Century.
It is a quite indefensible method of presenting world-history to
begin by giving rein to one’s own religious, political or social
convictions and endowing the sacrosanct three-phase system with
tendencies that will bring it exactly to one’s own standpoint. This is,
in effect, making of some formula—say, the “Age of Reason,”
Humanity, the greatest happiness of the greatest number,
enlightenment, economic progress, national freedom, the conquest
of nature, or world-peace—a criterion whereby to judge whole
millennia of history. And so we judge that they were ignorant of the
“true path,” or that they failed to follow it, when the fact is simply that
their will and purposes were not the same as ours. Goethe’s saying,
“What is important in life is life and not a result of life,” is the answer
to any and every senseless attempt to solve the riddle of historical
form by means of a programme.
It is the same picture that we find when we turn to the historians of
each special art or science (and those of national economics and
philosophy as well). We find:
“Painting” from the Egyptians (or the cave-men) to the
Impressionists, or
“Music” from Homer to Bayreuth and beyond, or
“Social Organization” from Lake Dwellings to Socialism, as
the case may
be,
presented as a linear graph which steadily rises in conformity with
the values of the (selected) arguments. No one has seriously
considered the possibility that arts may have an allotted span of life
and may be attached as forms of self-expression to particular
regions and particular types of mankind, and that therefore the total
history of an art may be merely an additive compilation of separate
developments, of special arts, with no bond of union save the name
and some details of craft-technique.
We know it to be true of every organism that the rhythm, form and
duration of its life, and all the expression-details of that life as well,
are determined by the properties of its species. No one, looking at
the oak, with its millennial life, dare say that it is at this moment, now,
about to start on its true and proper course. No one as he sees a
caterpillar grow day by day expects that it will go on doing so for two
or three years. In these cases we feel, with an unqualified certainty,
a limit, and this sense of the limit is identical with our sense of the
inward form. In the case of higher human history, on the contrary, we
take our ideas as to the course of the future from an unbridled
optimism that sets at naught all historical, i.e., organic, experience,
and everyone therefore sets himself to discover in the accidental
present terms that he can expand into some striking progression-
series, the existence of which rests not on scientific proof but on
predilection. He works upon unlimited possibilities—never a natural
end—and from the momentary top-course of his bricks plans
artlessly the continuation of his structure.
 “Mankind,” however, has no aim, no idea, no plan, any more than
the family of butterflies or orchids. “Mankind” is a zoological
expression, or an empty word.[17] But conjure away the phantom,
break the magic circle, and at once there emerges an astonishing
wealth of actual forms—the Living with all its immense fullness,
depth and movement—hitherto veiled by a catchword, a dryasdust
scheme, and a set of personal “ideals.” I see, in place of that empty
figment of one linear history which can only be kept up by shutting
one’s eyes to the overwhelming multitude of the facts, the drama of a
number of mighty Cultures, each springing with primitive strength
from the soil of a mother-region to which it remains firmly bound
throughout its whole life-cycle; each stamping its material, its
mankind, in its own image; each having its own idea, its own
passions, its own life, will and feeling, its own death. Here indeed are
colours, lights, movements, that no intellectual eye has yet
discovered. Here the Cultures, peoples, languages, truths, gods,
landscapes bloom and age as the oaks and the stone-pines, the
blossoms, twigs and leaves—but there is no ageing “Mankind.” Each
Culture has its own new possibilities of self-expression which arise,
ripen, decay, and never return. There is not one sculpture, one
painting, one mathematics, one physics, but many, each in its
deepest essence different from the others, each limited in duration
and self-contained, just as each species of plant has its peculiar
blossom or fruit, its special type of growth and decline. These
cultures, sublimated life-essences, grow with the same superb
aimlessness as the flowers of the field. They belong, like the plants
and the animals, to the living Nature of Goethe, and not to the dead
Nature of Newton. I see world-history as a picture of endless
formations and transformations, of the marvellous waxing and
waning of organic forms. The professional historian, on the contrary,
sees it as a sort of tapeworm industriously adding on to itself one
epoch after another.
But the series “ancient-mediæval-modern history” has at last
exhausted its usefulness. Angular, narrow, shallow though it was as
a scientific foundation, still we possessed no other form that was not
wholly unphilosophical in which our data could be arranged, and
world-history (as hitherto understood) has to thank it for filtering our
classifiable solid residues. But the number of centuries that the
scheme can by any stretch be made to cover has long since been
exceeded, and with the rapid increase in the volume of our historical
material—especially of material that cannot possibly be brought
under the scheme—the picture is beginning to dissolve into a chaotic
blur. Every historical student who is not quite blind knows and feels
this, and it is as a drowning man that he clutches at the only scheme
which he knows of. The word “Middle Age,”[18] invented in 1667 by
Professor Horn of Leyden, has to-day to cover a formless and
constantly extending mass which can only be defined, negatively, as
every thing not classifiable under any pretext in one of the other two
(tolerably well-ordered) groups. We have an excellent example of
this in our feeble treatment and hesitant judgment of modern
Persian, Arabian and Russian history. But, above all, it has become
impossible to conceal the fact that this so-called history of the world
is a limited history, first of the Eastern Mediterranean region and
then,—with an abrupt change of scene at the Migrations (an event
important only to us and therefore greatly exaggerated by us, an
event of purely Western and not even Arabian significance),—of
West-Central Europe. When Hegel declared so naïvely that he
meant to ignore those peoples which did not fit into his scheme of
history, he was only making an honest avowal of methodic
premisses that every historian finds necessary for his purpose and
every historical work shows in its lay-out. In fact it has now become
an affair of scientific tact to determine which of the historical
developments shall be seriously taken into account and which not.
Ranke is a good example.
 VIII
To-day we think in continents, and it is only our philosophers and
historians who have not realized that we do so. Of what significance
to us, then, are conceptions and purviews that they put before us as
universally valid, when in truth their furthest horizon does not extend
beyond the intellectual atmosphere of Western Man?
Examine, from this point of view, our best books. When Plato
speaks of humanity, he means the Hellenes in contrast to the
barbarians, which is entirely consonant with the ahistoric mode of the
Classical life and thought, and his premisses take him to conclusions
that for Greeks were complete and significant. When, however, Kant
philosophizes, say on ethical ideas, he maintains the validity of his
theses for men of all times and places. He does not say this in so
many words, for, for himself and his readers, it is something that
goes without saying. In his æsthetics he formulates the principles,
not of Phidias’s art, or Rembrandt’s art, but of Art generally. But what
he poses as necessary forms of thought are in reality only necessary
forms of Western thought, though a glance at Aristotle and his
essentially different conclusions should have sufficed to show that
Aristotle’s intellect, not less penetrating than his own, was of different
structure from it. The categories of the Westerner are just as alien to
Russian thought as those of the Chinaman or the ancient Greek are
to him. For us, the effective and complete comprehension of
Classical root-words is just as impossible as that of Russian[19] and
Indian, and for the modern Chinese or Arab, with their utterly
different intellectual constitutions, “philosophy from Bacon to Kant”
has only a curiosity-value.
It is this that is lacking to the Western thinker, the very thinker in
whom we might have expected to find it—insight into the historically
relative character of his data, which are expressions of one specific
existence and one only; knowledge of the necessary limits of their
validity; the conviction that his “unshakable” truths and “eternal”
views are simply true for him and eternal for his world-view; the duty
of looking beyond them to find out what the men of other Cultures
have with equal certainty evolved out of themselves. That and
nothing else will impart completeness to the philosophy of the future,
and only through an understanding of the living world shall we
understand the symbolism of history. Here there is nothing constant,
nothing universal. We must cease to speak of the forms of
“Thought,” the principles of “Tragedy,” the mission of “The State.”
Universal validity involves always the fallacy of arguing from
particular to particular.
But something much more disquieting than a logical fallacy begins
to appear when the centre of gravity of philosophy shifts from the
abstract-systematic to the practical-ethical and our Western thinkers
from Schopenhauer onward turn from the problem of cognition to the
problem of life (the will to life, to power, to action). Here it is not the
ideal abstract “man” of Kant that is subjected to examination, but
actual man as he has inhabited the earth during historical time,
grouped, whether primitive or advanced, by peoples; and it is more
than ever futile to define the structure of his highest ideas in terms of
the “ancient-mediæval-modern” scheme with its local limitations. But
it is done, nevertheless.
Consider the historical horizon of Nietzsche. His conceptions of
decadence, militarism, the transvaluation of all values, the will to
power, lie deep in the essence of Western civilization and are for the
analysis of that civilization of decisive importance. But what, do we
find, was the foundation on which he built up his creation? Romans
and Greeks, Renaissance and European present, with a fleeting and
uncomprehending side-glance at Indian philosophy—in short
“ancient, mediæval and modern” history. Strictly speaking, he never
once moved outside the scheme, not did any other thinker of his
time.
What correlation, then, is there or can there be of his idea of the
“Dionysian” with the inner life of a highly-civilized Chinese or an up-
to-date American? What is the significance of his type of the
“Superman”—for the world of Islam? Can image-forming antitheses
of Nature and Intellect, Heathen and Christian, Classical and
Modern, have any meaning for the soul of the Indian or the Russian?
What can Tolstoi—who from the depths of his humanity rejected the
whole Western world-idea as something alien and distant—do with
the “Middle Ages,” with Dante, with Luther? What can a Japanese do
with Parzeval and “Zarathustra,” or an Indian with Sophocles? And is
the thought-range of Schopenhauer, Comte, Feuerbach, Hebbel or
Strindberg any wider? Is not their whole psychology, for all its
intention of world-wide validity, one of purely West-European
significance?
How comic seem Ibsen’s woman-problems—which also challenge
the attention of all “humanity”—when, for his famous Nora, the lady
of the North-west European city with the horizon that is implied by a
house-rent of £100 to £300 a year and a Protestant upbringing, we
substitute Cæsar’s wife, Madame de Sévigné, a Japanese or a
Turkish peasant woman! But, for that matter, Ibsen’s own circle of
vision is that of the middle class in a great city of yesterday and to-
day. His conflicts, which start from spiritual premisses that did not
exist till about 1850 and can scarcely last beyond 1950, are neither
those of the great world nor those of the lower masses, still less
those of the cities inhabited by non-European populations.
All these are local and temporary values—most of them indeed
limited to the momentary “intelligentsia” of cities of West-European
type. World-historical or “eternal” values they emphatically are not.
Whatever the substantial importance of Ibsen’s and Nietzsche’s
generation may be, it infringes the very meaning of the word “world-
history”—which denotes the totality and not a selected part—to
subordinate, to undervalue, or to ignore the factors which lie outside
“modern” interests. Yet in fact they are so undervalued or ignored to
an amazing extent. What the West has said and thought, hitherto, on
the problems of space, time, motion, number, will, marriage,
property, tragedy, science, has remained narrow and dubious,
because men were always looking for the solution of the question. It
was never seen that many questioners implies many answers, that
any philosophical question is really a veiled desire to get an explicit
affirmation of what is implicit in the question itself, that the great
questions of any period are fluid beyond all conception, and that
therefore it is only by obtaining a group of historically limited
solutions and measuring it by utterly impersonal criteria that the final
secrets can be reached. The real student of mankind treats no
standpoint as absolutely right or absolutely wrong. In the face of
such grave problems as that of Time or that of Marriage, it is
insufficient to appeal to personal experience, or an inner voice, or
reason, or the opinion of ancestors or contemporaries. These may
say what is true for the questioner himself and for his time, but that is
not all. In other Cultures the phenomenon talks a different language,
for other men there are different truths. The thinker must admit the
validity of all, or of none.
How greatly, then, Western world-criticism can be widened and
deepened! How immensely far beyond the innocent relativism of
Nietzsche and his generation one must look—how fine one’s sense
for form and one’s psychological insight must become—how
completely one must free oneself from limitations of self, of practical
interests, of horizon—before one dare assert the pretension to
understand world-history, the world-as-history.
 IX
In opposition to all these arbitrary and narrow schemes, derived
from tradition or personal choice, into which history is forced, I put
forward the natural, the “Copernican,” form of the historical process
which lies deep in the essence of that process and reveals itself only
to an eye perfectly free from prepossessions.
Such an eye was Goethe’s. That which Goethe called Living
Nature is exactly that which we are calling here world-history, world-
as-history. Goethe, who as artist portrayed the life and development,
always the life and development, of his figures, the thing-becoming
and not the thing-become (“Wilhelm Meister” and “Wahrheit und
Dichtung”) hated Mathematics. For him, the world-as-mechanism
stood opposed to the world-as-organism, dead nature to living
nature, law to form. As naturalist, every line he wrote was meant to
display the image of a thing-becoming, the “impressed form” living
and developing. Sympathy, observation, comparison, immediate and
inward certainty, intellectual flair—these were the means whereby he
was enabled to approach the secrets of the phenomenal world in
motion. Now these are the means of historical research—precisely
these and no others. It was this godlike insight that prompted him to
say at the bivouac fire on the evening of the Battle of Valmy: “Here
and now begins a new epoch of world history, and you, gentlemen,
can say that you ‘were there.’” No general, no diplomat, let alone the
philosophers, ever so directly felt history “becoming.” It is the
deepest judgment that any man ever uttered about a great historical
act in the moment of its accomplishment.
And just as he followed out the development of the plant-form from
the leaf, the birth of the vertebrate type, the process of the geological
strata—the Destiny in nature and not the Causality—so here we
shall develop the form-language of human history, its periodic
structure, its organic logic out of the profusion of all the challenging
details.
 In other aspects, mankind is habitually, and rightly, reckoned as
one of the organisms of the earth’s surface. Its physical structure, its
natural functions, the whole phenomenal conception of it, all belong
to a more comprehensive unity. Only in this aspect is it treated
otherwise, despite that deeply-felt relationship of plant destiny and
human destiny which is an eternal theme of all lyrical poetry, and
despite that similarity of human history to that of any other of the
higher life-groups which is the refrain of endless beast-legends,
sagas and fables.
But only bring analogy to bear on this aspect as on the rest, letting
the world of human Cultures intimately and unreservedly work upon
the imagination instead of forcing it into a ready-made scheme. Let
the words youth, growth, maturity, decay—hitherto, and to-day more
than ever, used to express subjective valuations and entirely
personal preferences in sociology, ethics and æsthetics—be taken at
last as objective descriptions of organic states. Set forth the
Classical Culture as a self-contained phenomenon embodying and
expressing the Classical soul, put it beside the Egyptian, the Indian,
the Babylonian, the Chinese and the Western, and determine for
each of these higher individuals what is typical in their surgings and
what is necessary in the riot of incident. And then at last will unfold
itself the picture of world-history that is natural to us, men of the
West, and to us alone.
 X
Our narrower task, then, is primarily to determine, from such a
world-survey, the state of West Europe and America as at the epoch
of 1800-2000—to establish the chronological position of this period
in the ensemble of Western culture-history, its significance as a
chapter that is in one or other guise necessarily found in the
biography of every Culture, and the organic and symbolic meaning of
its political, artistic, intellectual and social expression-forms.
Considered in the spirit of analogy, this period appears as
chronologically parallel—“contemporary” in our special sense—with
the phase of Hellenism, and its present culmination, marked by the
World-War, corresponds with the transition from the Hellenistic to the
Roman age. Rome, with its rigorous realism—uninspired, barbaric,
disciplined, practical, Protestant, Prussian—will always give us,
working as we must by analogies, the key to understanding our own
future. The break of destiny that we express by hyphening the words
“Greeks = Romans” is occurring for us also, separating that which is
already fulfilled from that which is to come. Long ago we might and
should have seen in the “Classical” world a development which is the
complete counterpart of our own Western development, differing
indeed from it in every detail of the surface but entirely similar as
regards the inward power driving the great organism towards its end.
We might have found the constant alter ego of our own actuality in
establishing the correspondence, item by item, from the “Trojan War”
and the Crusades, Homer and the Nibelungenlied, through Doric and
Gothic, Dionysian movement and Renaissance, Polycletus and John
Sebastian Bach, Athens and Paris, Aristotle and Kant, Alexander
and Napoleon, to the world-city and the imperialism common to both
Cultures.
Unfortunately, this requires an interpretation of the picture of
Classical history very different from the incredibly one-sided,
superficial, prejudiced, limited picture that we have in fact given to it.
We have, in truth been only too conscious of our near relation to the
Classical Age, and only too prone in consequence to unconsidered
assertion of it. Superficial similarity is a great snare, and our entire
Classical study fell a victim to it as soon as it passed from the
(admittedly masterly) ordering and critique of the discoveries to the
interpretation of their spiritual meaning. That close inward relation in
which we conceive ourselves to stand towards the Classical, and
which leads us to think that we are its pupils and successors
(whereas in reality we are simply its adorers), is a venerable
prejudice which ought at last to be put aside. The whole religious-
philosophical, art-historical and social-critical work of the 19th
Century has been necessary to enable us, not to understand
Æschylus, Plato, Apollo and Dionysus, the Athenian state and
Cæsarism (which we are far indeed from doing), but to begin to
realize, once and for all, how immeasurably alien and distant these
things are from our inner selves—more alien, maybe, than Mexican
gods and Indian architecture.
Our views of the Græco-Roman Culture have always swung
between two extremes, and our standpoints have invariably been
defined for us by the “ancient-mediæval-modern” scheme. One
group, public men before all else—economists, politicians, jurists—
opine that “present-day mankind” is making excellent progress,
assess it and its performances at the very highest value and
measure everything earlier by its standards. There is no modern
party that has not weighed up Cleon, Marius, Themistocles, Catiline,
the Gracchi, according to its own principles. On the other hand we
have the group of artists, poets, philologists and philosophers. These
feel themselves to be out of their element in the aforesaid present,
and in consequence choose for themselves in this or that past epoch
a standpoint that is in its way just as absolute and dogmatic from
which to condemn “to-day.” The one group looks upon Greece as a
“not yet,” the other upon modernity as a “nevermore.” Both labour
under the obsession of a scheme of history which treats the two
epochs as part of the same straight line.
In this opposition it is the two souls of Faust that express
themselves. The danger of the one group lies in a clever
superficiality. In its hands there remains finally, of all Classical
Culture, of all reflections of the Classical soul, nothing but a bundle
of social, economic, political and physiological facts, and the rest is
treated as “secondary results,” “reflexes,” “attendant phenomena.” In
the books of this group we find not a hint of the mythical force of
Æschylus’s choruses, of the immense mother-earth struggle of the
early sculpture, the Doric column, of the richness of the Apollo-cult,
of the real depth of the Roman Emperor-worship. The other group,
composed above all of belated romanticists—represented in recent
times by the three Basel professors Bachofen, Burckhardt and
Nietzsche—succumb to the usual dangers of ideology. They lose
themselves in the clouds of an antiquity that is really no more than
the image of their own sensibility in a philological mirror. They rest
their case upon the only evidence which they consider worthy to
support it, viz., the relics of the old literature, yet there never was a
Culture so incompletely represented for us by its great writers.[20] The
first group, on the other hand, supports itself principally upon the
humdrum material of law-sources, inscriptions and coins (which
Burckhardt and Nietzsche, very much to their own loss, despised)
and subordinates thereto, often with little or no sense of truth and
fact, the surviving literature. Consequently, even in point of critical
foundations, neither group takes the other seriously. I have never
heard that Nietzsche and Mommsen had the smallest respect for
each other.
But neither group has attained to that higher method of treatment
which reduces this opposition of criteria to ashes, although it was
within their power to do so. In their self-limitation they paid the
penalty for taking over the causality-principle from natural science.
Unconsciously they arrived at a pragmatism that sketchily copied the
world-picture drawn by physics and, instead of revealing, obscured
and confused the quite other-natured forms of history. They had no
better expedient for subjecting the mass of historical material to
critical and normative examination than to consider one complex of
phenomena as being primary and causative and the rest as being
secondary, as being consequences or effects. And it was not only
the matter-of-fact school that resorted to this method. The
romanticists did likewise, for History had not revealed even to their
dreaming gaze its specific logic; and yet they felt that there was an
immanent necessity in it to determine this somehow, rather than turn
their backs upon History in despair like Schopenhauer.
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