Gynaecological Cancers Malcolm Padwick MD FRCOG. Cervical Cancer.
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Transcript of Gynaecological Cancers Malcolm Padwick MD FRCOG. Cervical Cancer.
Cervical CancerCervical Cancer
• 1992 national targets set for year 1992 national targets set for year 20002000
1. Reduce mortality by 20%1. Reduce mortality by 20%
2. Achieve 80% smear uptake2. Achieve 80% smear uptake• 1991 targets had already been 1991 targets had already been
achievedachieved• Mortality rate had been falling since Mortality rate had been falling since
1950 at a rate of 1 -2 % per annum1950 at a rate of 1 -2 % per annum• Now 2.3 per 100000 Now 2.3 per 100000
At risk groupsAt risk groups
Young (immature TZ)Young (immature TZ) Early age of first sexual intercourseEarly age of first sexual intercourse Multiple partnersMultiple partners SmokingSmoking Type of contraceptionType of contraception Screening historyScreening history
Screening intervals Screening intervals (2004)(2004)
Age Group Age Group (years)(years)
Frequency of Frequency of Screening Screening
2525 First invitationFirst invitation
25 - 4925 - 49 3 yearly3 yearly
50 - 6450 - 64 5 yearly5 yearly
65+65+ No screen since No screen since age 50 yrs or age 50 yrs or recent recent abnormal smearabnormal smear
HPVHPV
HPV subtyping will become HPV subtyping will become availableavailable
1.1. Concentrate screening on Concentrate screening on genuinely at risk womengenuinely at risk women
2.2. Allow an increase in the screening Allow an increase in the screening intervalinterval
3.3. Avoid unnecessary intervention Avoid unnecessary intervention
Referral to ColposcopyReferral to Colposcopy
3 inadequate smears3 inadequate smears 2 mildly dyskariotic / borderline 2 mildly dyskariotic / borderline
smearssmears First moderately or severely First moderately or severely
dyskariotic smeardyskariotic smear Glandular abnormalitiesGlandular abnormalities Suspicion of malignancySuspicion of malignancy
Colposcopy visitColposcopy visit
Information sheets with appointmentInformation sheets with appointment Separate clinic waiting areaSeparate clinic waiting area Changing and washing facilitiesChanging and washing facilities Separate consultation areaSeparate consultation area Comply with NHSCSP appointment Comply with NHSCSP appointment
waiting timeswaiting times Comply with NHSCSP waiting times Comply with NHSCSP waiting times
for resultsfor results
Scale of problemScale of problem
Watford referrals Watford referrals 19951995
228 new patients228 new patients
Watford referrals Watford referrals 20032003
618 new patients618 new patients
Therefore a follow-up policy change introduced (NHS)
ColposcopyColposcopy
Assess Assess
1.1. Biopsy and act on results when Biopsy and act on results when availableavailable
2.2. See and treatSee and treat
After effectsAfter effects
3 weeks of diminishing blood stained 3 weeks of diminishing blood stained dischargedischarge
Risk of secondary infection at 1 weekRisk of secondary infection at 1 week Next period often heavy and painfulNext period often heavy and painful Overall post operative pain is minimalOverall post operative pain is minimal >98% have a clear or better smear >98% have a clear or better smear
result at 6 monthsresult at 6 months
Cervical cancerCervical cancer
From colposcopyFrom colposcopy General clinic with abnormal General clinic with abnormal
bleedingbleeding Acute admission with symptoms of Acute admission with symptoms of
advanced diseaseadvanced disease
StagingStaging
EUA and cystoscopyEUA and cystoscopy Pelvic MRIPelvic MRI Abdominal and chest CTAbdominal and chest CT
Normal uterine anatomyNormal uterine anatomy
Pre-menopausalPre-menopausal Post-menopausalPost-menopausal
Stage IIIB - Stage IIIB - pelvic sidewall orpelvic sidewall or ureteric uretericobstructionobstruction
MRI signs:MRI signs:nn Same findings as IIB withSame findings as IIB with
involvement of obturator,involvement of obturator,piriformispiriformis, levators muscles, levators muscles
nn HydroureterHydroureter
TreatmentTreatment
SurgerySurgery
1.1. Cone biopsyCone biopsy
2.2. Radical trachylectomyRadical trachylectomy
3.3. Radical hysterectomyRadical hysterectomy
4.4. Neoadjuvant chemotherapy Neoadjuvant chemotherapy combined with radical surgerycombined with radical surgery
5.5. exenterationexenteration
TreatmentTreatment
Chemo-radiation as a primary Chemo-radiation as a primary treatmenttreatment
Radiotherapy as post operative Radiotherapy as post operative treatment for poor prognostic treatment for poor prognostic diseasedisease
Chemotherapy or radiotherapy for Chemotherapy or radiotherapy for palliationpalliation
consequencesconsequences
SurgerySurgery
1.1. Acute complicationsAcute complications
2.2. FistulaFistula
3.3. Bladder dysfunctionBladder dysfunction
4.4. Body imageBody image
General improvement with time.General improvement with time.
consequencesconsequences ChemoradiationChemoradiation1.1. AlopeciaAlopecia2.2. Radiation burnsRadiation burns3.3. Vaginal stenosis and inflammationVaginal stenosis and inflammation4.4. Cystitis and colitisCystitis and colitis5.5. Fistula bowel and bladderFistula bowel and bladder
Side effects tend to get worse with time.Side effects tend to get worse with time.
The futureThe future
Improved preventionImproved prevention Less invasive treatment for pre-Less invasive treatment for pre-
cancercancer vaccinationvaccination
outcomeoutcome
Stage Stage
II
IIII
IIIIII
IVIV
5 year survival5 year survival
80%80%
60%60%
20%20%
5%5%
Malcolm Padwick MD Malcolm Padwick MD FRCOGFRCOG
Gynaecologist Gynaecologist
West Herts NHS TrustWest Herts NHS Trust
General impressionGeneral impression
Middle class diseaseMiddle class disease Effects older populationEffects older population Silent killerSilent killer One of the diseases GPs fear missing One of the diseases GPs fear missing
the mostthe most
Mortality 12 per 100000
At risk groupsAt risk groups
Post menopausalPost menopausal NulliparousNulliparous Family history (including breast Family history (including breast
cancer)cancer) Contraceptive usageContraceptive usage EndometriosisEndometriosis EnvironmentalEnvironmental
Screening Screening
• Genetic - BRCA 1 and 2 mutationsGenetic - BRCA 1 and 2 mutationsUSS and CA125 ?????USS and CA125 ?????
Prophylactic oopherectomy after 40 years Prophylactic oopherectomy after 40 years
+/- HRT+/- HRT• General populationGeneral population
USS and CA125 ?????USS and CA125 ?????
Research projects onlyResearch projects only
presentationpresentation
Abdominal distensionAbdominal distension Abnormal PV bleedingAbnormal PV bleeding Abdominal discomfortAbdominal discomfort DyspepsiaDyspepsia Bowel symptomsBowel symptoms From physicians and general From physicians and general
surgeonssurgeons
ManagementManagement
MDTMDT Surgery +/- chemotherapySurgery +/- chemotherapy Staging and randomization into Staging and randomization into
interval debulking studyinterval debulking study Interval debulkingInterval debulking Pregnancy associated massPregnancy associated mass
Follow-upFollow-up
CA125CA125 CTCT Relapse chemotherapyRelapse chemotherapy Relapse surgery Relapse surgery
OutcomeOutcome
StageStage
II
IIII
IIIIII
IVIV
5 Year survival5 Year survival
90%90%
70%70%
25%25%
5%5%
Endometrial CancerEndometrial Cancer
65 of all cancers in women65 of all cancers in women postmenopausal postmenopausal obese (hypertensive, diabetic)obese (hypertensive, diabetic) HRTHRT tamoxifentamoxifen
SymptomsSymptoms
PMBPMB IMBIMB PCBPCB Pap smearPap smear PainPain Weight loss, bowel and bladder Weight loss, bowel and bladder
changeschanges Abnormal bleeding on HRTAbnormal bleeding on HRT
ManagmentManagment
Refer to the “rapid access clinic”Refer to the “rapid access clinic” Use cancer pro formaUse cancer pro forma
InvestigationsInvestigations
Pelvic USSPelvic USS If endometrial signal > 4mm for If endometrial signal > 4mm for
endometrial biopsy -- either pippelle endometrial biopsy -- either pippelle or hysteroscopy and currettageor hysteroscopy and currettage
High risk symptoms go straight to H High risk symptoms go straight to H & C& C