Cervical Cancer

Dr. Swapna Chaudhary M.S. (MUM) Consultant Obstetrician & Gynaecologist Infertility Specialist

Cervix

Cervix constitutes lower 1/3 rd of uterus

Epidemiology

5 lac new cases / year around world

Epidemiology 5 lac new cases / year around world 80% in developing countries

Epidemiology 5 lac new cases / year around world 80% in developing countries Commonest gynecological malignancy in India

Epidemiology 5 lac new cases / year around world 80% in developing countries Commonest gynecological malignancy in India 2 nd is breast cancer

Risk Factors / Causes

Multiple sexual partners (> 1)

Risk Factors / Causes Multiple sexual partners (> 1) Young age at marriage / first intercourse

Risk Factors / Causes Multiple sexual partners (> 1) Young age at marriage / first intercourse Early childbearing / Multiparity

Risk Factors / Causes Multiple sexual partners (> 1) Young age at marriage / first intercourse Early childbearing / Multiparity Prior STDs (HSV II, genital warts, vaginal infections)

Risk Factors / Causes Multiple sexual partners (> 1) Young age at marriage / first intercourse Early childbearing / Multiparity Prior STDs (HSV II, genital warts, vaginal infections) Cigarette Smoking

Risk Factors / Causes Multiple sexual partners (> 1) Young age at marriage / first intercourse Early childbearing / Multiparity Prior STDs (HSV II, genital warts, vaginal infections) Cigarette Smoking Immunodeficiency

Risk Factors / Causes Multiple sexual partners (> 1) Young age at marriage / first intercourse Early childbearing / Multiparity Prior STDs (HSV II, genital warts, vaginal infections) Cigarette Smoking Immunodeficiency Human Papiloma Virus (HPV) – transforms normal cell into malignant cells

Age Groups

Cervical Intraepithelial Neoplasia (CIN) 35 years

Age Groups Cervical Intraepithelial Neoplasia (CIN) 35 years Invasive Cervical Cancer years

Symptoms

CIN (dysplasia): Asymptomatic

Symptoms CIN (dysplasia): Asymptomatic Invasive Cancer 1.No classic presentation

Symptoms CIN (dysplasia): Asymptomatic Invasive Cancer 1.No classic presentation 2.Abnormal bleeding -- intercycle -- post coital -- post menopausal

Symptoms CIN (dysplasia): Asymptomatic Invasive Cancer 1.No classic presentation 2.Abnormal bleeding -- intercycle -- post coital -- post menopausal 3. Foul smelling vaginal discharge

4.Chronic backache / pelvic pain

5.Late sign -- weight loss -- mild fever -- anemia

Dysplasia / CIN

Precancerous stage

Dysplasia / CIN Precancerous stage First series of changes leading to cancer

Dysplasia / CIN Precancerous stage First series of changes leading to cancer Age of presentation – 35 yrs

Dysplasia / CIN Precancerous stage First series of changes leading to cancer Age of presentation – 35 yrs CIN

Dysplasia / CIN Precancerous stage First series of changes leading to cancer Age of presentation – 35 yrs CIN

Dysplasia / CIN Precancerous stage First series of changes leading to cancer Age of presentation – 35 yrs CIN I mild

Dysplasia / CIN Precancerous stage First series of changes leading to cancer Age of presentation – 35 yrs CIN I II mild mod

Dysplasia / CIN Precancerous stage First series of changes leading to cancer Age of presentation – 35 yrs CIN I II III mild mod severe

25 % patients progress from CIN 1 to CIN 3 in 2 yrs

40 % patients of CIN 3 progress to Cancer over 10 – 15 yrs.

Pap Smears

Non invasive OPD procedure

Pap Smears Non invasive OPD procedure No pain / no discomfort

Pap Smears Non invasive OPD procedure No pain / no discomfort No anesthesia required

When to Get Pap Smears

ACOG Recommendations

When to Get Pap Smears ACOG Recommendations –1st Pap Smear at age when patient becomes sexually active (or by age 18)

When to Get Pap Smears ACOG Recommendations –1st Pap Smear at age when patient becomes sexually active (or by age 18) –Yearly pap smears thereafter

When to Get Pap Smears ACOG Recommendations –1st Pap Smear at age when patient becomes sexually active (or by age 18) –Yearly pap smears thereafter Others contend that monogamous women with no history of abnormal pap smears can have them done every 3 years

When to Get Pap Smears ACOG Recommendations –1st Pap Smear at age when patient becomes sexually active (or by age 18) –Yearly pap smears thereafter Others contend that monogamous women with no history of abnormal pap smears can have them done every 3 years After 40 – yrly pap test for 3 yrs – if normal then 3 yrly.

Routine screening can stop at age of 60 yrs provided….

Routine screening can stop at age of 60 yrs provided 1.Previous 2 normal smears

Routine screening can stop at age of 60 yrs provided 1.Previous 2 normal smears 2.No abnormal smear in last 10 yrs

Routine screening can stop at age of 60 yrs provided 1.Previous 2 normal smears 2.No abnormal smear in last 10 yrs Routine screening not required for patients who had hysterectomy for benign disease (eg. Fibroid)

Performing Pap Smear

Cervix visualised – superficial layer of cells in cervical canal taken on a spatula or swab stick – spread on a slide, fixed and stained with Papanicolou stain – examined under mircoscope

Performing Pap Smear Cervix visualised – superficial layer of cells in cervical canal taken on a spatula or swab stick – spread on a slide, fixed and stained with Papanicolou stain – examined under mircoscope If abnormal cells seen – patient referred for biopsy

Evaluating the Pap Smear

First, the smear is evaluated for adequacy of sample

Evaluating the Pap Smear First, the smear is evaluated for adequacy of sample Secondly the sample is categorized as “normal” or “other”

Evaluating the Pap Smear First, the smear is evaluated for adequacy of sample Secondly the sample is categorized as “normal” or “other” Lastly, all sample categorized as “other” are further specified as infection, inflammation, CIN or Cancer suspect

Evaluating the Pap Smear First, the smear is evaluated for adequacy of sample Secondly the sample is categorized as “normal” or “other” Lastly, all sample categorized as “other” are further specified as infection, inflammation, CIN or Cancer suspect (biopsy confirmation).

What to Inform Patients Prior to Obtaining Pap Smear

No douching or usage of vaginal medications, lubricants, or spermicides within 2-3 days of exam (these products may hide abnormal cells)

What to Inform Patients Prior to Obtaining Pap Smear No douching or usage of vaginal medications, lubricants, or spermicides within 2-3 days of exam (these products may hide abnormal cells) Schedule Pap Smear between days of menstrual cycle, if possible

What to Inform Patients Prior to Obtaining Pap Smear No douching or usage of vaginal medications, lubricants, or spermicides within 2-3 days of exam (these products may hide abnormal cells) Schedule Pap Smear between days of menstrual cycle, if possible Abstain from intercourse 1-2 days prior to smear

Improving Access to Pap Smears

50% of patients who die of cervical cancer have never had a Pap Smear

Improving Access to Pap Smears 50% of patients who die of cervical cancer have never had a Pap Smear Uninsured, older patients and those who live in rural areas have limited access to Pap Smears

Improving Access to Pap Smears 50% of patients who die of cervical cancer have never had a Pap Smear Uninsured, older patients and those who live in rural areas have limited access to Pap Smears These groups must be targeted to reduce rates of cervical cancer.

Treatment

Surgery for early stage 1

Treatment Surgery for early stage 1 Stage 2 onwards radiotherapy and / or surgery

Prognosis

CIN cure rate 95 – 100%

Prognosis CIN cure rate 95 – 100% Stage 1 – after treatment – 5 yr survival 80%

Prognosis CIN cure rate 95 – 100% Stage 1 – after treatment – 5 yr survival 80% Decreased to 14 % for Stage 4

Thank you