1. Cervical Cancer

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

3. Cervix

4. Cervix constitutes lower 1/3 rd of uterus

5. Epidemiology

6. 5 lac new cases / year around world

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

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

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

10. Risk Factors / Causes

11. Multiple sexual partners (> 1)

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

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

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

15. 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

16. 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

17. 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

18. Age Groups

19. Cervical Intraepithelial Neoplasia (CIN) 35 years

20. Age Groups Cervical Intraepithelial Neoplasia (CIN) 35 years Invasive Cervical Cancer 45 - 55 years

21. Symptoms

22. CIN (dysplasia): Asymptomatic

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

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

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

26. 4.Chronic backache / pelvic pain

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

28. Dysplasia / CIN

29. Precancerous stage

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

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

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

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

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

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

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

37. 25 % patients progress from CIN 1 to CIN 3 in 2 yrs

38. 40 % patients of CIN 3 progress to Cancer over 10 – 15 yrs.

39. Pap Smears

40. Non invasive OPD procedure

41. Pap Smears Non invasive OPD procedure No pain / no discomfort

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

43. When to Get Pap Smears

44. ACOG Recommendations

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

46. 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

47. 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

48. 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.

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

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

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

52. 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)

53. Performing Pap Smear

54. 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

55. 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

56. Evaluating the Pap Smear

57. First, the smear is evaluated for adequacy of sample

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

59. 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

60. 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).

61. What to Inform Patients Prior to Obtaining Pap Smear

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

63. 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 12-16 of menstrual cycle, if possible

64. 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 12-16 of menstrual cycle, if possible Abstain from intercourse 1-2 days prior to smear

65. Improving Access to Pap Smears

66. 50% of patients who die of cervical cancer have never had a Pap Smear

67. 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

68. 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.

69. Treatment

70. Surgery for early stage 1

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

72. Prognosis

73. CIN cure rate 95 – 100%

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

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

76. Thank you