cervical cancer. dr. swapna chaudhary m.s. (mum) consultant obstetrician & gynaecologist...

Cervical Cancer

Cervical Cancer

Dr. Swapna Chaudhary M.S. (MUM)

Consultant Obstetrician & Gynaecologist

Infertility Specialist

Cervix

Cervix

• Cervix constitutes lower 1/3rd of uterus

Epidemiology

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• 2nd is breast cancer

Risk Factors / Causes

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

Age Groups

• Cervical Intraepithelial Neoplasia (CIN) 35 years

Age Groups

• Cervical Intraepithelial Neoplasia (CIN) 35 years• Invasive Cervical Cancer 45 - 55

years

Symptoms

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

4. Chronic backache / pelvic pain

5. Late sign -- weight loss

-- mild fever

-- anemia

Dysplasia / CIN

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

• 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

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

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

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

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

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 12-16 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 12-16 of menstrual cycle, if possible

• Abstain from intercourse 1-2 days prior to smear

Improving Access to Pap Smears

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

Treatment

• Surgery for early stage 1

Treatment

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

surgery

Prognosis

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