CERVICAL CANCER………prevention is the best cure

An insight from Indian Menopause Societywww.indianmenopausesociety.org

Prof. M.C. Bansal.MBBS MS .MICOG.FICOG.

Founder Principal & Controller ;Jhalawar Medical College and Hospital ,

Jhalawar.Ex. Principal & Controller;

Mahatma Gandhi Medical College And Hospital ,

Sitapura, Jaipur.

What is Cancer? Hippocrates was the first to use the word “cancer” to describe tumors Cancer is derived from the Greek word “karkinos” which means crab It is thought Hippocrates was referring to the appearance of tumors.

The main portion of the tumor being the crabs body and the various extensions of the tumor appear as the legs and claws of the crab.

• Changes to the DNA of a cell (mutations) lead to cellular damage

• Mutations enable cancer cells to divide continuously, without the need for normal signals

• In some cancers the unchecked growth results in a mass, called a tumor

• Cancerous cells may invade other parts of the body interfering with normal body functions

What is Cancer?

What is Cancer?

Although cancer is often referred to as if it were a single disease, it is really a diverse group of diseases that affects many different organs and cell types

The likelihood of developing any particular cancer depends on an individual’s genetics, environment, and lifestyle.

The occurrence of some cancers may be prevented/reduced by wise lifestyle choices.

Common Female Genital Cancers

• Cancer Cervix

• Cancer Breast

• Cancer Endometrium

• Cancer Ovary

• Vulvar/ vaginal cancers

• others

Cervix• Lower part of the uterusLower part of the uterus• Connects the body of the uterus to Connects the body of the uterus to

the vagina (birth canal)the vagina (birth canal)• In developing countries like India In developing countries like India

this is the most common organ to this is the most common organ to be involved in malignancybe involved in malignancy

• This is the part of body which is This is the part of body which is readily amenable to clinical readily amenable to clinical examination. examination.

Source: American Cancer SocietySource: American Cancer Society

Cancer Cervix

• One of the most preventable and curable malignancies

• More than 75% cases belong to developing countries.

• Incidence falling by about 7% per annum in developed countries due to operational screening programs

What is Cervical Cancer? Cervical cancer is a slow developing cancer that starts in the interior lining of

the cervix. Almost all cases begin with changes caused by the human papillomavirus (HPV), a sexually transmitted infection.

Over time the changes caused by HPV build up and a pre-cancerous condition called cervical intraepithelial neoplasia (CIN) develops.

CIN can progress to cervical cancer, but this is not always the case.

Image Courtesy of QIAGENwww.qiagen.com

India ~1,32,000 World ~ 4,93,000

India ~27% of new Cervical Cancer cases in world

India ~ 74,000World ~ 2,73,000

India ~27%

Rest of World - 73%

India ~27% of deaths due to Cervical Cancer in world

Rest of World - 73%

India - 27%

Burden of disease

New Cervical Cancer Cases Deaths due to Cervical cancer

India ~27%

Rest of World - 73%

Bhatla N et al; Vaccine 2008; 26 2811-17

What Causes Cancer?

Some known cancer causing agents (carcinogens) with which you might interact:

How to reduce your cancer risk:

Tobacco (cigarettes and

smokeless)

Viruses (HPV, EBV)

UV Radiation (sun, tanning bed)

DON’T: Smoke

DO: make healthy lifestyle

choices

DO: get available vaccines

DO: use sunscreenDON’T: excessively

exposure yourself to UV radiation (tanning beds,

sun)

What predisposes you……….

When to consult…….

• Abnormal Vaginal bleedingAbnormal Vaginal bleeding

• Menstrual bleeding is longer and heavier than usualMenstrual bleeding is longer and heavier than usual

• Bleeding after menopause or increased vaginal Bleeding after menopause or increased vaginal dischargedischarge

• Bleeding following intercourse or pelvic examBleeding following intercourse or pelvic exam

• Pain during intercoursePain during intercourse

Source: American Cancer SocietySource: American Cancer Society

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Continuum of Care for Cervical Cancer Continuum of Care for Cervical Cancer ControlControl

15 years 30 years 45 years

Vaccination Screening and treatment

Cancer treatment

Source: WHO 2006

All Women

HPV and Cervical Cancer

About 80% of Womenwill be infected with HPV in their lifetime

HPV and Cervical Cancer

Source: Gynecologic Cancer Foundation

About 7% of Women will have an abnormal Pap test

HPV and Cervical Cancer

300,000 Women (per year in the United States) will have a high grade precancerous lesions

HPV and Cervical Cancer

About 9-25per100,000 Women (per year in India) will develop cervical cancer

HPV and Cervical Cancer

Progression

HPV 20%

LSIL

HSIL 33%

CANCER

Precancerous conditions

Cancer Screening

• Procedure by which cancer can be detected in precancerous/ early stage to make the treatment effective.

• According to WHO cervical cancer is the only preventable cancer of female genital tract as the precancerous changes of cervix can be diagnosed way before the development of cancer by the screening methods.

Barriers to women’s participation in screening

• Little understanding of cervical cancer• Limited understanding of female reproductive organs and

associated diseases• Lack of access to services• Shame and fear of a vaginal exam• Fear of death from cancer• Lack of trust in health care system• Lack of community and family support• Concept of “preventive care” is foreign

Screening tools for cervical cancer

• Visual inspection of cervix

• Pap smear– Conventional– Liquid based cytology

• Viral typing for high risk HPV subtypes

• Combination of Pap smear and HPV

• Colposcopy

Pap Test – An Important Step in Women’s Health

Cervical Cancer Screening

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What Is a Pap Test?

A Pap test is a simple procedure which involves gently scraping some cells from the surface of the cervix and putting them on a slide. The cells are examined under a microscope to see if they are normal.

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• Cells in the lining of the cervix may gradually change from normal to precancer to cancer, usually over several years

• Pre and early cancerous changes in the cervix can be found by the Pap test (also called the “Pap smear”)

• Since precancers and very early cervical cancers are nearly 100% curable, this test can prevent nearly all deaths from cervical cancer

• Early cervical cancer or precancers usually show no symptoms or signs

Why is Pap Testing Important?

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When to Begin Pap Tests?How Often?

United States Guidelines

• Begin getting annual Pap tests when you start to be sexually active, or if you are at least 18 years old

• If three or more annual Pap tests have been normal, then Pap testing may be done less frequently if recommended by the doctor

Is there an age when I can stop having Pap tests?

The American Cancer Society recommends that screening stop at age 70 if three or more recent tests are normal, and there have been no abnormal results in the last 10 years.

ACOG recommendations

• First screen - three years after first sexual intercourse or

by age 21 whichever comes first• Women up to age 30 - annual cervical cytology• Women 30 years and older - two screening options cervical cytology alone combination of cytology and HPV

Grades of Dysplasia

How your smear report is interpreted –there are grades of involvement of your lining of cervix depending upon the depth of involvement of the covering layer of cervix

What happens if I have anabnormal Pap test?

Depending on your Pap test result your provider may advise one or more of the following: – HPV testing– Repeat Pap– Colposcopy– Possibly an endometrial biopsy – Possible referral to gynecologic

oncologist

HPV typing

• Viral typing for high risk HPV subtypes i.e. 16,18,31,45.

• High risk HPV infection seen with over 90% Ca Cervix and 80% high grade dysplasia worldwide

• More sensitive than Pap smear

• Presently an expensive test for screening general population

HPV typing

• 80% HPV infections are transient

• 20% infections convert into CIN

• Regression occurs in majority with-

- low grade lesions

- low risk HPV subtypes mainly 6 & 11

- women under 30 years of age

HPV Vaccines

• Quadrivalent HPV Vaccine – Gardasil by Merck & Co.

• Bivalent HPV Vaccine – Cervarix by GSK

Colposcopy

• Not an organized screening tool

• Used to examine surfaces of cervix, vagina and vulva

• Image reflects the appearance of connective tissue through a filter formed by the epithelial layer

• Magnification used is 10-15 fold commonly

• Low specificity i.e. < 50% in low grade CIN

Normal transformation zone

Colposcopic appearance-VIA

Colposcopic view- VILI

CIN 3

What are the treatment options for CIN?

• There are a variety of effective options for treatment. Most are outpatient or office treatments. Treatment names that you might hear include:– LEEP

– Laser

– Cryotherapy

– Cone Biopsy

– Rarely, a hysterectomy may be recommended

What is new in screening and prevention?

• Liquid cytology-thin layer cytology. This is where your cervical swab is placed in a container instead of ‘smeared’ on a slide.

• Combination of HPV test and Pap is now available for screening women 30 years of age and older. This helps identify patients at increased risk for developing cervical cancer.

• Pap test imaging by computer reviews in addition to a review by trained personnel.

• Vaccines for cervical cancer

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A Woman’s Life Requires Balancing Important Responsibilities

WorkFamily

Health

Taking care of her health is key

Diet and exercise

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A Pap test is an important part of a periodic health exam for women

Add a Periodic Health Exam to Your Seasonal Routine

Health Checkups

Mid-Autumn FestivalChristmas

Message

• Annual gynaecological check up and cancer screening a must for all asymptomatic sexually active and adult females

• Gynaecological check up indicated for all symptomatic women

Aim

Females are the essence of life so let us decide today to instill life in this essence and vow to eradicate the fear and suffering from diseases especially gynaecological cancers.

CONTRIBUTORS

CONCEPT:

Dr. Sunila Khandelwal

President, IMS

DESIGNED BY:

Dr. Ranu Patni

Secy. General, IMS

Dr. Seema Sharma

Chapter Secy. Jaipur, IMS