Cervical carcinoma – trends and treatments Miss Kathryn Hillaby MD MRCOG Consultant Gynaecological Oncologist, Colposcopy Lead for Gloucestershire

Cervical Carcinoma – where are we now? Total cases in England in 2008 = 2,369 Mortality = 753 women in 2008 1 yr relative survival rate = 86% 5 yr relative survival rate = 68%

Cervical carcinoma Peak incidence 35-39 Incidence rates have halved in UK in last 20 yrs Linked to HPV and smoking

Cervical carcinoma Number of cases highest in those aged 25-49, these women represent over half of all diagnoses Rates peak in women in early 30’s, gradually reduce in 40’s and rise again in women in 70’s and early 80’s Both incidence and mortality worse in deprived areas Cervical cancer is worse in older women – 1 yr survival in those aged 15-39 is 96% compared with 52% in those aged 80 or older

Cervical Carcinoma

Cervical carcinoma Incidence and mortality rates have fallen considerably over past 20 yrs Incidence rates have almost halved (16.2 to 8.3 per 100,000 female population) Mortality rates reduced by 2/3 (from 6.4 to 2.2 per 100,000 female population) Incidence fell sharply following introduction of Cervical screening programme

Cervical carcinoma HOWEVER: Reduction in incidence has levelled off in recent years Between 1998 and 2008 incidence in women aged 25-29 increased by 77%

Worldwide Cervical carcinoma 12th most common cancer in women, and 5th most deadly In young women is 2nd most common carcinoma 80% occurs in developing countries Kills 250,000 women per year

Map of incidence by Cancer Network, 2004-2008

Map of mortality by Cancer Network, 2004-2008

Cervical carcinoma

Cervical carcinoma Colposcopy – apply acetic acid to cervix Biospy or LLETZ - Squamous cell carcinoma (85%) Adenocarcinoma (15%)

Colposcopy

Cervical carcinoma staging Staging is clinical FIGO staging Based on EUA, cystoscopy +/- sigmoidoscopy Does NOT include MRI In UK investigations include MRI pelvis and CT chest/abdo/pelvis

Cervical carcinoma Investigations – CT and MRI EUA and cystoscopy

Stage 1 disease Stage 1A Stage 1A1 = <3mm depth of invasion and <7mm wide Stage 1A2 = 3-5mm depth of invasion and <7mm wide Treatment = LLETZ

Stage 1 disease Stage 1B = any tumour which is visible Stage 1B1 = <4cm Stage 1B2 = >4cm Confined to cervix Treatment = surgical for 1B1 Chemo Radiotherapy for 1B2

Stage 2 disease Stage 2 = invades beyond uterus, but not to pelvic sidewall or lower 1/3 of vagina Stage 2A – spread into the top of the vagina 2A1 = <4cm 2A2 = >4cm

Stage 2 disease Stage 2B – spread into parametrium

Stage 3 disease Tumour extends to pelvic sidewall and/or involves lower 1/3 of vagina and/or causes hydronephrosis Stage 3A – Cancer has spread to lower 1/3 of vagina, but not to pelvic sidewall

Stage 3 disease Stage 3B disease Spread to pelvic sidewall and / or hydronephrosis

Stage 4 Carcinoma has extended beyond true pelvis or has involved mucosa of bladder or rectum Stage 4a – spread of growth to adjacent organ

Stage 4 disease Stage 4B – spread to distant organs

Staging and treatment Surgical in women up to stage 1b1 Chemotherapy (cisplatin) with radiotherapy in women with disease > stage 1b1

Cervical carcinoma 36 cases Stage 1B1 and above per year Gloucestershire, Herefordshire and S Worcestershire Stage 1b1 or less managed surgically Stage 1b2 and above managed with chemo-radiotherapy Survival rates >85% in women <40yrs

How can we tackle this? Reduce incidence by screening Treatment – of CIN to stop progression to cervical cancer Early detection of cervical carcinoma Adequate treatment

Cervical screening programme Cervical screening programme saves 4500 lives per year in UK Cervical screening prevents up to 3,900 cases of cervical cancer per year in the UK

Cervical screening programme Early detection can prevent 75% cervical cancers Currently between 77-83% women attend for screening 2007/2008 43% women 25-34yrs did not attend for smears

What happened? 2008-2009 statistics show that the number of women of all ages having cervical screening has increased to 3.7 million compared with 3.4 million last year, an increase of 10.5 per cent (around 353,000). Those within the 25 to 64 age range have risen to 3.6 million from 3.2 million last year, an 11.9 per cent increase (around 384,000). The majority of this increase is for women aged 25 to 49. It is thought to be due to the publicity surrounding the illness and death of Jade Goody.

Take home messages Cervical screening programme works Prevents 70% cases cervical carcinoma Saves 4500 women per year Only works if women attend for smear HPV vaccine prevents 70% cases cervical cancer Uptake currently disappointing