DR GEETANJALI S VERMACSI RAINY MULTISPECIALITY HOSPITAL

“For most of history, Anonymous was a woman.”

Virginia Wool

HISTORY OF WOMEN’S DAY

• This was first celebrated on 19th March 1911 but is now celebrated every 8th March.

• Women join to celebrate the date that represents equality, justice,peace and development.

• International Women’s Day is rooted in the struggle of women seeking to participate on an equal footing with men.

Mary Wollstonecraft• She was the first woman to

demand votes for women.• 1792 her book entitled

Vindication of the Rights of Women argued for equal education, and for single women to earn their own living.

• She fought hard for women even though she had much personal unhappiness. Unfortunately this led her to being criticised and her ideas dismissed by many, including women.

Rich Victorian Women

• Although rich women had an easier life they had a common denominator with poor women: they had no legal status. A married woman’s earnings belonged to her husband. Her property and goods all belonged to her husband.

• A woman could not vote.• A woman could no go to university.• She could not get a divorce on grounds of adultery

(although her husband could).• It was almost impossible to get a divorce at all until 1857.• The law said that children had one parent, a father. He

decided on their education and if a couple separated he could refuse to let the mother even see them.

Caroline Norton

Caroline had a brutal husband who accused her of adultery. She was unable to defend herself in court as she had no legal status. Her husband took her children and also all her earnings (she was a writer). Caroline wrote on the Custody of Infants and had some effect: 1839 the bill said children under seven could stay with their mother if the courts agreed she had a good character. Caroline also wrote on making divorce laws fairer. Therefore she helped legal equality for women.

Barbara Bodichon

Barbara supported the Married Women’s Property Bill in 1856. This resulted in an Acts of Parliament allowing women living with husbands or those separated to keep their own earnings By 1882 women could own their own property and give it to whoever she wished.

Voting: arguments used against women

• Women are incapable of rational thought.• Women are physically too frail and weak to

take on the burden of decision.• Women are incapacitated by frequent

childbearing to bother to vote.• Men will make the right decisions for them.• If women have the vote they will upset the

current order and cause unpleasant changes.

“In politics, If you want anything said, ask a man. If you want anything done, ask a woman.”

Margaret Thatcher

FROM NO VOTING RIGHTS TO RULING

“You educate a man; you educate a man. You educate a woman; you educate a generation.”

Brigham Young

Florence Nightingale

• Worked as a nurse in the Crimean and drastically reduced the death rate.

• Introduced nursing as a profession and started a nursing school.

• Involved in improving military hospitals

• Used health statistics effectively

• Hospital planning• Community nursing.

Mary Seacole

• A nurse who used herbs and natural remedies.

• Self funded to go to the Crimean and nurse soldiers on the battlefield - a true ‘field’ nurse attending the wounded on the front line

• Sometimes called the ‘forgotten Nightingale’.

Women in WWI and WWII

Munitions factory

Mother Theresa

A Catholic nun who devoted her life to caring for the poor and sick in Calcutta, India. She was revered as a living saint for her work and won the Nobel Peace Prize.

Marie Curie

• She won two Nobel prizes for her work in science.

• Discovered radium with her husband Pierre

• In WWI she equipped ambulances with mobile X ray units and drove them to the front lines

• Her work helped X rays in surgery

• Her research led to treatment of cancer by radiation.

CANCERS IN WOMEN

BREAST CANCER

EPIDEMIOLOGY

Incidence:• Breast cancer is the most common lethal

neoplasm in women.• The incidence varies among different

populations– 1 out of 8 women will have BC in her life--time.– ~ 25 percent of women with cancer have BC.

• The incidence of male breast canceris about 1% of all breast cancer cases occur in men.

US incidence

– Affects 1 in 8 women living to 85yrs age– Total cases 2008 : 211,000– Total deaths : 40,500 (1/6th of female deaths) Ethnic incidence

Causacians – hispanic - asians – african american Stage at presentation

localised 58% (node -)Regional 32% (node + / stage 3)

Age Incidenceby age 30 1 in 2,525by age 40 1 in 217by age 50 1 in 50by age 60 1 in 24by age 70 1 in 14by age 80 1 in 10

RISK FACTORS• Highly elevated RF (relative at 4 times risk)

– Female– Age>50yrs– Personal history of prior breast cancer– Family history– Atypical proliferative benign breast disease esp with family history

• Moderately elevated RF (relative at 2 - 4 times risk)– Any 1st degree relative with breast cancer– Upper SES– Prolonged interrupted menses– Post menopausal obesity– h/o cancer ovary or endometrium– proliferative benign breast with no atypia

• Slightly elevated RF (relative at 1-2 times risk)– Moderate alcohol intake– Menarche <12yrs old– HRT/ OCP/ Diet

PATHOLOGYNon – Invasive

Lobular (LCIS) Ductal (DCIS) Invasive

Low Risk* Standard (high) RiskPure Tubular DuctalPure Mucinous/Colloid LobularPure Papillary Medullary **Pure Medullary ? Mixed

Squamous

* Requires careful pathology review** atypical and mixed

CLINICAL PRESENTATION

The majority of carcinoma in situ, T1, or T2: • Painless or slightly tender breast mass or have an

abnormal screening mammogram. • Patients with more advanced tumors:

breast tenderness, skin changes, bloody nipple discharge, or occasionally change in the shape and size of the breast.

• Rarely patients may present with axillary lymphadenopathy (which occasionally may be painful) or distant metastasis.

SCREENING

MAMMOGRAPHYEstablished Guidelines

Annual 2 view study in women 50 years of age and older

• Meta - analysis– 13 randomized trials– 26% reduction in breast cancer

• Screening– Patient without physical finding or symptoms• MLO - mediolateral oblique (side)• CC - craniocaudal (above)

• Diagnostic– new symptoms - lump, thickening, skin change– additional imaging including magnification– additional evaluation including US

• INTERPRETATION

BIRADS - Breast Imaging Reporting and Data System

Category Assessment Recommendations0 Incomplete Additional views1 Negative Routine - 12 months2 Benign Routine - 12 months3 Probable BenignF/U short term -6mos.4 Suspicious Biopsy considered5 Cancer suggested Appropriate action

DIAGNOSIS

• Fine Needle Aspiration

• Ultrasound Guided Core Biopsy

• Excisional or Incisional Biopsy

TREATMENT• NON INVASIVE DUCTAL

1) Complete Excision Alone

2) Complete Excision + RT

3) Mastectomy

Margins need to be negative,>1mm, less than 10 mm. 2-3 mm usually recommended

Post excision Imaging - specimen mammogram and/or - post lump mammogram

Relative Contraindications 1 – in 2 or more quadrants 2 – diffuse or malignant appearing Ca++ 3 – persistent + margins 4 – not RT candidates

prior RTpregnancyCTD –

lupus/scleroderma

Possible for low risk lesion, but “low risk” difficult to define

Management Options – Radiation Therapy

• Excision Alone – recommended• Post Mastectomy – unnecessary• No effect on mortality• Decreases Breast Recurrence Risk by 50% (1% ½

%/yr)Treatment is to Breast OnlyContraindications:Omitted in low risk? controversial < 5mm, low grade, unicentric

Relative Contraindications 1 – in 2 or more quadrants 2 – diffuse or malignant appearing Ca++ 3 – persistent + margins 4 – not RT candidates

prior RTpregnancyCTD – lupus/scleroderma

NON INVASIVE LOBULAR

FeaturesIncreased risk of subsequent invasive cancer (~ 1%/yr)Likely to be bilateral

Management OptionsObservation ( negative surgical margins NOT required)

No SLNBx or ALND is necessaryBilateral mastectomies can be consideredPotential candidates for Tamoxifen or chemoprevention trials

Work-Up/Follow-UpBilateral mammogram, then yearlyExam every 6-12 months

INVASIVE

Stages I – IIB + IIIA (T3 > 5 cm, N1 only)Management Priorities

Surgery

Adjuvant Chemotherapy

Hormonal Rx* Radiation Rx*

CERVICAL CANCER

Where is the cervix?

• Cervical cancer is the second most common cancer among women and is the primary cause of cancer-related deaths in developing countries

•Cervical cancer, in women, is the second most common cancer worldwide, next only to breast cancer. In India, cervical cancer is the most common woman-related cancer, followed by breast cancer

Introduction

• Cancer of the cervix is the most common female genital cancer in developing countries. Every year about 500,000 women , acquire the disease and 75% are from developing countries.

• The cervical cancer burden in India alone is estimated to be 100,000 .

•The number of deaths due to cervical cancer is estimated to rise to 79,000 by the year 2010. •The cancer mostly affects middle- aged women (between 40 and 55 years), especially those from the lower economic status who fail to carry out regular health check-ups due to financial inadequacy.

In urban areas, cancer of the cervix account for over 40% of cancers while in rural areas it accounts for 65% of cancers as per the information from the cancer registry

INCIDENCE

Risk factors and aetiology HPV (Human papilloma virus ) infection

mainly 16,18 the main aetiological is infection with subtypes of HPV (16,18)

Coitus at young age: <16 years old increased risk by 50%

Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.

Smoking Smoking for> 12 years increase the risk by

12.7 folds

Previous CIN

Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.

Barrier method decrease the risk Immuno suppresive pt Low socioecomic class

Type of patient:

• Multiparous.• Low socioeconomic class.• Poor hygiene.• Prostitute.

Predisposing factors:

• Cervical dysplasia.• Cervical intraepithelial neoplasia• CIN III / CARCINOMA IN SITU• THE LESION PROCEEDS THE INVASION BY 10-

12 YEARS The cervical cancer burden in

Symptoms:

Early symptoms Late symptoms

- None.- Thin, watery, blood

tinged vaginal discharge frequently goes unrecognized by the patient.

- Abnormal vaginal bleeding

IntermenstrualPostcoitalPerimenopausalPostmenopausal- Blood stained foul

vaginal discharge.

- Pain, leg oedema.- Urinary and rectal

symptomsdysuriahaematuriarectal bleedingconstipationhaemorrhoids- Uraemia

Pathology type

• Squamous cell carcinoma- 90%.• Adenocarcinoma- 10%.

What do you know about cervical cancer screening?

What is a Pap test?

• Can find abnormal changes on the cervix.

• Treating early changes can prevent cancer of the cervix.

Pap test…

Cervical cancer prevention

• Pap smears performed once per year until age 30

• >30 yrs - once every 3 yrs if pap and HPV negative

• 75% reduction in cervical cancer in countries with adequate screening

STAGES OF CANCER CERVIX

• Once cancer cervix is found (diagnosed), more tests will be done to find out if the cancer cells have spread to other parts of the body. This testing is called staging.

• TO PLAN TREATMENT, A DOCTOR NEEDS TO KNOW THE STAGE OF THE DISEASE.

TREATMENT

• Surgical.• Radiotherapy.• Radiotherapy & Surgery.• Radiotherapy and Chemotherapy followed by

Surgery.• Palliative treatment.

Surgical procedure

• The classic surgical procedure is the wertheim’s hystrectomy for stage Ib,IIa, and some cases of IIb in young and fat patient

PROGNOSIS

Depends on:• Age of the patient.• Fitness of the patient.• Stage of the disease.• Type of the tumour.• Adequacy of treatment.

THE OVERALL 5 YEARS SURVIVAL FOLLOWING THERAPY:

• Stage I -------80%• Stage II-------50-60%• Stage III-------30-40%• Stage IV-------4%

HPV-associated Conditions

HPV 16, 18Cervical cancerHigh/low grade cervical abnormalitiesAnal, Vulvar, Vaginal, Penile

Head and neck cancers

HPV 6, 11Low grade cervical abnormalitiesGenital wartsRRP

Estimated %70%

30%-50%

10%

10%

90%90%

Human Papillomavirus Vaccines

• HPV4 (Gardasil)– contains types 16 and 18 (high risk) and types 6

and 11 (low risk)• HPV2 (Cervarix)– contains types 16 and 18 (high risk)

• Both vaccines are supplied as a liquid in a single dose vial or syringe

• Neither vaccine contains an antibiotic or a preservative

Human Papillomavirus Vaccines

• HPV4 vaccine is approved for

– females 9 through 26 years of age for the prevention of cervical cancers, precancers and genital warts

– males 9 through 26 years of age for the prevention of genital warts

• HPV2 vaccine is approved for

– females 10 through 25 years of age for the prevention of cervical cancers and precancers

– not approved for males or for the prevention of genital warts

HPV Vaccine Schedule and Intervals

• HPV4- 0, 2, 6 months• HPV2- 0, 1, 6 months• ACIP recommends- 0, 1 to 2, 6 months• ACIP has not defined a maximum interval

between HPV vaccine doses • If the interval between doses is longer than

recommended continue the series where it was interrupted

Conclusions• Cervical cancer affects women in our

community• Cervical cancer is a serious disease – Risks just from preventing cancer– 30% mortality from cervical cancer– Long term effects after treatment for cervical

cancer• Cervical cancer is preventable– Regular pap smears– HPV vaccination

THANKYOU