CANCER CERVIX A PREVENTABLE CANCER Dr NEETA DHABHAI Sr Consultant. – Gynaecologist Member Expert - Indian Cancer Winners’ Association

Anatomy of female pelvis The cervix is the lower part of the uterus. It extends into the vagina. Of all gynecologic cancers, cervical cancer is the second most common among all women and the most common among younger women. It usually affects women aged 35 to 55, but it can affect women as young as 20. The cervix is the lower part of the uterus. It extends into the vagina. Of all gynecologic cancers, cervical cancer is the second most common among all women and the most common among younger women. It usually affects women aged 35 to 55, but it can affect women as young as 20.

Incidence of Cancer Cervix

Cancer of Uterine Cervix

> 200 women die every day Every 7 minutes a women dies 8 women die every hour Cervical Cancer : India This ‘Cause’ need to be taken up by multiple stake holders. Cervical Cancer in India

Indian scenario  Commonest cancer in women in India  Major cause of deaths in women due to cancer  Usually diagnosed at advanced stage  No National program  Uniformly low incidence of cervical screening in India (6% in rich & 4% in poor)

HIGH-RISK FACTORS Women with a history that includes: Lower socioeconomic status Lower socioeconomic status Multiple sexual partners Multiple sexual partners Early onset of sexual activity (at or before age 17) Early onset of sexual activity (at or before age 17) Multiple pregnancies and poor birth spacing Multiple pregnancies and poor birth spacing Woman with current or former history : Human papillomavirus infections- type 16,18,31,35 Human papillomavirus infections- type 16,18,31,35 HIV HIV

HIGH-RISK FACTORS-Others Women with medical histories which include: Immunosupression Immunosupression Smoking Smoking Oral contraceptives Oral contraceptives Substance abuse, including alcohol Substance abuse, including alcohol Lack of screening (women who have had Pap smears at least every 3 years have 1/10 the risk of invasive disease than women who have never had one) Lack of screening (women who have had Pap smears at least every 3 years have 1/10 the risk of invasive disease than women who have never had one)

HPV 16 HPV 18 HPV 6 HPV 11 Cancer causing Types Non-cancer causing types >75% of Cervical Cancer ~50% of Vaginal & Vulvar Cancer 90% of Anogenital warts HPV is a necessary cause of cervical cancer % HPV Human Papilloma Virus (HPV)

Changes in Cervical Epithelium by HPV Infection Normal Cervix HPV Infection / CIN* 1 CIN 2 / CIN 3 / Cervical Cancer *CIN = cervical intraepithelial neoplasia

Natural History of HPV & Cervical Cancer Normal Cervix HPV Infection Pre-cancer Cancer Infection Progression Invasion Regression Clearance Persistence Persistence

HPV Infection Low Grade Lesions High Grade Lesions Invasive Cancer 0–1 Year0–5 Years1–20 Years HPV Infection may clear Facts about HPV Infection

Diagnosis of Cancer Cervix History & Physical exam: History & Physical exam: No symptoms No symptoms Irregular Bleeding PV Irregular Bleeding PV Vaginal discharge (foul smelling, blood stained) Vaginal discharge (foul smelling, blood stained) Post coital spotting Post coital spotting Cervical growth Cervical growth If no visible growth If no visible growth PAP smear PAP smear Colposcopy Colposcopy Endocervical curettage Endocervical curettage

How to prevent Cancer Cervix

MOST IMPORTANT METHOD FOR MOST IMPORTANT METHOD FOR PREVENTION AND EARLY DETECTION PREVENTION AND EARLY DETECTION OF CANCER CERVIX IS BY OF CANCER CERVIX IS BY CERVICAL SCREENING WITH PAP’S CERVICAL SCREENING WITH PAP’S SMEAR SMEAR

Pap smear - guidelines  Target group - All women aged yrs who have ever had sex  Timing of Initial Screening - Initial screening at age of 21 years or within 3 years of sexual activity Initial screening at age of 21 years or within 3 years of sexual activity Screening interval – Screening interval – Yearly till the age of 30 then every 2 to 3 yearly if test results have been normal for 3 years in a row. Yearly till the age of 30 then every 2 to 3 yearly if test results have been normal for 3 years in a row.  When to End Screening - After 70 yrs if test results have been normal for at least 3 years in a row and no result has been abnormal in the last 10 years. - After 70 yrs if test results have been normal for at least 3 years in a row and no result has been abnormal in the last 10 years. - Post Hysterectomy - Post Hysterectomy

For women at high risk of HPV, the HPV test can be done at the same time as a Pap test. Screening Test for HPV

Colposcopy Colposcopy is often done if results of a Papanicolaou (Pap) test are abnormal. For colposcopy, cervix is inspected for signs of cancer. Often, a sample of tissue is removed for examination (biopsy). Colposcopy alone (without biopsy) is painless and thus requires no anesthetic.

Treatment The main treatment of gynecologic cancer is surgical removal of the tumor. Surgery may be followed by radiation therapy or chemotherapy.

Prognosis Prognosis depends on the stage of the cancer. With treatment, 80 to 90% of women with stage I cancer and 50 to 65% of those with stage II cancer are alive 5 years after diagnosis.

HPV Vaccine

Are HPV vaccines safe?

Vaccine Profile: Side Effects Side Effects QuadrivalentBivalent Local: Pain at inj. Site ( mild to moderate) 83%90% Local: Swelling and erythema 25%40% Fever4%12% No serious vaccine related adverse effects with both vaccine

3 DOSES 0, 2MTHS 6MTHS INTRAMUSCULAR DOSE, METHOD OF ADMINISTRATION AND USAGE

Cancer Cervix IS PREVENTABLE, IF Detected EARLY!!!!!!!!! THANK YOU

 HPV is a necessary cause of cervical cancer – 99.7%  Induction of neutralising antibodies by vaccination is critical for protection  HPV 16 & 18 cause ~75% * of cervical cancer cases while HPV 6 & 11 cause ~90% genital warts  27% of the world burden of Cervical Cancer is seen in India.  Every 7 minutes a woman dies in India due to cervical cancer  Cervical Cancer is usually diagnosed in late stages in India.  Cervical cancer screening is recommended in women >30yrs  Vaccination between 9-26yrs can be an effective strategy to help reduce this huge disease burden. * India

Thank You For Your Comments