Published on November 26, 2012
CERVICALCANCER???... THIS IS DONE BY: S.DHARSHINEE GOOD SHEPHERD 1 INTERNATIONA
WHAT IS CERVICAL CANCER??? It is a cancer which occurs in the cervix of a women. Cervical cancer begins in the cervix. The cervix is the lower part of the womb, called the uterus. It opens to the vagina. Cervical cancer was once the number-one cause of death from cancer in women. Thanks to the Pap test, which can screen for this cancer, the number of women in the United States with cervical cancer has decreased dramatically. With the Pap test, doctors can also find changes in the cervix when they are still precancerous. It is the only gynecological cancer, currently, that can be prevented through routine screening. 2
WHAT IS A FEMALE REPRODUCTIVETRACT???• Vulva• Vagina• Cervix• Uterus• Fallopian tubes• Ovaries 3
WHAT IS A CERVIX????• The cervix is one part of your reproductive system.• It is the lower part of your womb, also called the uterus.• The cervix connects your uterus and vagina.• And your vagina leads to the outside of your body and the vulva, which is the skin area where you have pubic hair.• These are the other parts of your reproductive system.• They are all in your pelvis. 4
IS CERVICAL CANCER VERY COMMON? LETSSEE HOW COMMON IT IS….. 500,000 women worldwide die of cervical cancer annually 50-60 million women in the U.S. have a Pap test each year 3-5 million women in the U.S. have an abnormal result 12,200 new cervical cancers diagnosed in the U.S. per year 4,100 deaths from cervical cancer in the U.S. per year. 5
THE SYMPTOMS OF CERVICAL CANCER Unusual discharge from the vagina. Blood spots or light bleeding when youre not having your periods. Bleeding after menopause. Bleeding or pain during sex. Anemia because of abnormal vaginal bleeding. Ongoing pelvic, leg, or back pain. Urinary problems because of blockage of a kidney or ureter. Bleeding from the rectum or bladder. Weight loss. 6
WHAT CAUSES CERVICAL CANCER???The main cause for cervical cancer is a viruscalled (HPV)human papillomavirus…. • HPV is sexually transmitted • The HPV detected today could have been acquired years ago • There are many different types of HPV Low-risk types can cause warts High-risk types can cause pre cancer and cancer of the cervix 7
HOW COMMON IS HPV(HUMANPAPILLOMAVIRUS)???? Most men and women who have had sex have been exposed to HPV More than 75% of sexually active women tested have been exposed to HPV by age 18-22…. Some doctors think it is almost as common as the cold virus. In the United States, over 6 million people (men and women) get an HPV infection every year. At least one-half of the people who have ever had sex will have HPV at some time in their life. It is especially common among young people. The CDC reported in 2009 that about 45% of women aged 20 to 24 had HPV (there are no tests for HPV in men). And among girls aged 15 to 19, about 25% had HPV. 8
WHO IS AT RISK OF HPV???? Women who have ever had sex Women who have had more than one partner Women whose partner (s) has had more than one sexual partner Women with other sexually transmitted diseases Women who do not have Pap tests Women with immune problems Steroid medications Transplanted organs Chemotherapy HIV Women who smoke 9
HOW DO I REDUCE MY RISK OF GETTINGHPV??? Delay onset of sexual activity Know your sexual partner Do not smoke Maintain a healthy diet and lifestyle Practice safe sex GET A PAP TEST DONE….. 10
GET A PAP SMEAR DONE…. Strong sensitivity and specificity Accuracy of Smear Requires adequate sample presence of enough inflamation and dysplasia quick fixation of specimen to glass slide 11
WHEN TO GET A PAP SMEAR… 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 12
HOW A PAP SMEAR IS DONE??? Patient asked to lie on her back at edge of exam table with feet in stirrups Metal or plastic speculum is inserted into vagina to expand the wall of vagina to enable access to cervix Cells are collected using cotton swab, wooden spatula, or cervical brush and smeared onto glass slide Preservative sprayed to prevent cells from drying and artifacts from forming Slide evaluated by lab technician who looks for abnormalities in the 50,000 to 300,000 cells on 13 slide
THE CLASSIFICATION OF THE PAP SMEAR… The Class System (I to V) The CIN System (CIN I to III) characterizes the degree of cellular abnormalities The SIL System (Bethesda System) Lesions characterized as LGSIL or HGSIL Presence of HPV noted This scheme is most widely used system these days 14
THE EVALUATION OF 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, or various stages of cancer 15
DURING OR BEFORE THE PAP SMEAR ONE SHOULDFOLLOW THE THINGS LISTED… 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 16
SOMETIMES THERE IS A PITFALL DIAGNOSTICOF CERVICAL CANCER… 30% of cases of cervical cancer are missed due to errors interpreting results of pap smears Ways of Improving Pap Smears rescreen portions of slide deemed negative to reduce false-negatives new liquid smears may be have higher sensitivty and specificity usage of computerized devices to analyze smear (PAPNET, VIRAPAP) 17
ACCESS TO PAP SMEAR… 50% of patients who die of cervical cancer have never had a Pap Smear Uninsured, minorities, older patients and those who live in rural areas have limited access to Pap Smears These groups must be targeted to further reduce rates of cervical cancer in the US 18
WHAT IS A PAP TEST???? A test which collects cells from the surface of the cervix and looks for any abnormal cells Abnormal cells can be treated before cervical cancer develops When cancer is detected early, it is easier to treat 19
HOW OFTEN SHOULD I HAVE A PAP TESTDONE???• Every year until age 30• After age 30, if you have only had normal results, you may have them every two to three years after discussion with your physician and evaluation of your risk factors. 20
WHY IS A PAP TEST IMPORTANT??? A Pap test can find treatable changes of the cervix (precancer) before you have a symptom or notice a problem. Once a problem is symptomatic, it is harder to treat. 21
WHICH IS THE BEST TIME TO HAVE A PAPTEST DONE??? Schedule your Pap when you are not having a menstrual period. It is best to abstain from intercourse and avoid use of tampons or douches for two days before your Pap test 22
WHY SHOULD I KEEP TESTING??? The test is not perfect. Changes (abnormalities) may occur since the last test. It may take many years for changes to develop or be detected. Your risk changes if you have new partners. 23
WHAT SHOULD I EXPECT WHEN I HAVEA PAP TEST???o Feet are placed in stirrups (foot holders)o A speculum (thin duck-billed instrument) is inserted into vagina to see the cervixo You may have brief discomfort which is usually mildo You may have some spotting afterward 24
HOW DO I GET TO KNOW ABOUT MYRESULTS??? You may ask to have a copy mailed to you You may call for your results If you have an abnormal result, it is extremely important to follow-up for the recommended testing Even after a normal Pap test, it is still important to report any symptoms of abnormal vaginal bleeding, discharge or pain to your doctor and call to be seen right away 25
IS IT COMPULSORY TO HAVE A PAP TEST IF IHAD A HYSTERECTOMY???• If you had treatment for precancer or cancer of the cervix, you may need a Pap test• If the cervix was left in place at the time of your hysterectomy, you will still need Pap tests• Preventive health care is still important even if you do not need a Pap test 26
AT WHICH AGE CAN I STOP HAVING PAP TESTDONE??? 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 If you are 70 or older with a history of normal results, you are at very low risk of cervical cancer and do not need Pap test. If you have sex with a new partner, this may change your risk. Talk to your health care provider about if and when you need a Pap test. 27
WHAT IS NEW IN SCREENING ANDPREVENTION??? Liquid cytology-thin layer cytology Combination of HPV test and Pap is now available for women 30 years of age and older Pap test computer reviews Vaccines for HPV currently being tested. 28
WHAT IS A HPV TEST??? A test sometimes used to determine if you need further evaluation Cells are collected just like a Pap test It checks for high-risk HPV An HPV test is sometimes useful to determine if you need any further evaluation. This is particularly true for the minimally abnormal Pap tests with atypical squamous cells of undetermined significance, often abbreviated as ASC-US. The HPV test is collected just like a Pap test. In fact, if the Pap test is collected in a liquid, then the HPV test can be run on that liquid if the Pap test shows minimally abnormal results. The test checks for high-risk HPV. The FDA approved HPV DNA test (DNA with Pap) can identify 13 different high-risk HPV types. About 90% of cervical cancers are caused by one of these 13 types. 29
WHAT HAPPENS IF I HAVE AN ABNORMALPAP TEST??? ASC-US management options: HPV testing Repeat Pap Colposcopy ASC-H, LSIL, HSIL, AGC, AIS, cancer Colposcopy Possibly endometrial biopsy for AGC AIS / cancer: referral to gynecologic oncologist There is a spectrum of Pap test results from “normal to “cancer or carcinoma.” In between normal and cancer, there is a range of abnormalities, such as ASC- US (the abbreviation for atypical squamous cells of undetermined significance) or LSIL (low-grade squamous intraepithelial lesions) to more significant cellular changes, such as HSIL (high-grade squamous intraepithelial lesions), AGC (atypical glandular cells) or AIS (adenocarcinoma in situ). The abnormalities called ASC-US sometimes harbor pre-cancer changes, but most often reflect inflammation, hormonal changes or an infection with the human papillomavirus. If your Pap test shows ASC-US, any of the following three management options may be chosen as the next step by you and your doctor: HPV testing, repeat Pap tests at approximately six month intervals or immediate colposcopy. A Pap test is only a screening test. 30
WHAT IS A COLPOSCOPY??? Colposcopy: Use of a magnifying instrument Application of a vinegar-like solution onto the cervix See abnormalities that can’t be seen with the naked eye Feels like getting a Pap test, but lasts longer. The first step in the evaluation of an abnormal Pap test is a colposcopy. Colposcopy is a test that helps find abnormal areas in the cervix. This is done in the doctor’s office. Similar to the examination for obtaining a Pap test, a speculum will be placed into the vagina. A nurse or doctor then applies a vinegar-like solution onto the cervix and examines the cervix with the colposcope, which is a magnifying lens with a strong light. If there are abnormal areas, a biopsy may be taken. 31
WHAT IS A CERVICAL BIOPSY?Biopsy:• Removal of a small piece of tissue from the cervix• May feel like getting a Pap test or like a menstrual cramp that lasts a few secondsDuring a biopsy, a very small piece of tissue isremoved so that a pathologist can evaluate it undera microscope to make a diagnosis. Any visibleabnormality of the cervix should be biopsied tomake sure of the diagnosis. Having a biopsy takenmay cause some discomfort, like a menstrualcramp that lasts a few seconds.Sometimes, your doctor will also perform anendocervical curettage, in which a little bit of tissuewill be scraped from the cervical canal in order toexamine it more closely under the microscope.And, at times colposcopy with biopsies andendocervical curettage is not enough to find theexplanation for the abnormal Pap test and to makesure of the diagnosis. In this situation, a conization 32is performed, during which a larger, cone-shapedpiece of tissue is removed from the cervix.
WHAT DOES THE BIOPSY RESULT MEAN? Mildly abnormal (CIN I) observation preferred More abnormal (CIN II) treatment Precancer (CIN III) treatment Cancer Gynecologic oncology consultation The pathologist examines all tissues under the microscope. Similar to what was discussed earlier for the Pap test, biopsy results can show a broad spectrum with the two extremes being “normal” and “cancer or carcinoma”. In between, there is a range of abnormalities called CIN I to III. CIN stands for cervical intraepithelial neoplasia. CIN III is a pre-cancer change. This means the cells are highly abnormal, but do not yet invade or spread like cancer cells. It is important to understand that treatment depends on the biopsy results, NOT the Pap test. For CIN I management options include treatment or observation. Which route of management is right for you will depend on a number of factors. Observation is often preferred over immediate therapy since the chance that CIN I spontaneously regresses to normal is about 60%. However, about 10% will progress to more severe abnormalities. Therefore, a schedule of repeat examinations will be needed when CIN I is diagnosed, often Pap tests every six months. CIN II and III should always be treated. If any invasive cancer has been found, you should be seen by a gynecologic oncologist to determine what treatment you will need. 33
WHAT ARE THE TREATMENT OPTIONS FORCIN??? LEEP Laser Cryotherapy Cone Biopsy In special circumstances a hysterectomy may be recommended If you need treatment for CIN, there are multiple treatment options such as LEEP, laser, cryotherapy, and cone biopsy. Options can be divided into two main groups: those that remove the area of abnormality (LEEP, cone biopsy) and those that destroy the area of abnormality (cryotherapy, laser vaporization). Each of those have their indications, advantages and disadvantages, but, importantly, cure rates are comparable. In special circumstances a hysterectomy may be recommended. 34
WHAT CAN I EXPECT AFTER TREATMENT FORCIN??? Estimates of cure range from 73-90% with a single treatment The risk for invasive cancer following treatment is about 1% Therefore, you still need to have regular Pap tests Minimal, if any, impact on fertility Cryotherapy, LEEP, laser and conization are similar in their ability to treat CIN. Estimated cure rates range from 73% to 90% with a single treatment. However, 10% to 27% of patients will have future problems with CIN, making close follow-up after treatment very important. Once a patient has been treated for CIN, her risk for developing invasive cervical cancer is about 1%. One major concern regarding treatment of cervical pre-cancers has been the potential that fertility may be decreased. Treatment of CIN could make it more difficulty to get pregnant or to carry the baby to full-term. This could happen because of cervical stenosis (scarring of the opening of the womb), decreasing cervical mucous formation or cervical incompetence (weakening of the cervix with difficulties of holding the baby inside the womb until term). However, there is little evidence that a single treatment leads to changes of either fertility or pregnancy outcomes. 35
WHAT YOU CAN DO?Take Control - Protect Yourself Ask your doctor about an appropriate Pap test screening interval for you Make sure that you get a Pap test at the recommended time Find out how and when you will learn about the results of your Pap test Follow-up! Don’t assume that no news is good news Do not smoke. 36
WHAT ARE THE SYMPTOMS OF CERVICALCANCER??? Abnormal bleeding Between periods With intercourse After menopause Unusual vaginal discharge Other symptoms Leg pain Pelvic pain Bleeding from the rectum or bladder Some women have no symptoms 37
WHAT SHOULD I DO IF I HAVE JUST BEENDIAGNOSED WITH CERVICAL CANCER??? Find a gynecologic oncologist Discuss treatment options Conization Hysterectomy Radical hysterectomy Radiation with chemotherapy Ask about clinical trials Other considerations Preserve your fertility Preserve your ovaries Often times cervical cancer is first diagnosed by a primary care provider. Once the diagnosis is suspected or confirmed, the primary care provider will help find a gynecologic oncologist. These physicians are expert in the diagnosis and treatment of cervical cancer. Women with cervical cancer are encouraged ask about clinical trials. Co-operative group trials are performed at many institutions around the country and your gynecologic oncologist can suggest appropriate trials. Radical hysterectomy and chemoradiation are the most common treatments for cervical cancer. Even with a diagnosis of cervical cancer, a woman may have the option of preserving her ability to have children and to keep her ovaries. 38
CLINICAL STAGING OF CERVICAL CANCER…The clinical stage is the extent of cancer at thetime of diagnosis. Staging is necessary so thatphysicians can accurately communicate witheach other about the disease. This allowsdoctors to discuss treatment options, toconsider enrollment in clinical trials and tocompare the outcomes in efforts to improvequality of care. Clinical staging is completedbefore treatment begins.Cervical cancer can be broken into 4 generalgroups.Stage IStage IA cancers are cancers with minimalinvasion that can only be detectedmicroscopically.Stage IB cancers are those that involve only thecervix. The cancers that are larger than 4 cm areclassified as stage IB2.Stage IIA stage IIA cervix cancer indicates that there hasbeen spread of the cancer to involve both thecervix and upper portion of the vagina.A cancer is defined as stage IIB if there isextension of the cancer into the tissue next tothe cervix.Stage IIIA stage IIIA cervical cancer has involvement ofthe lower vagina and a IIIB has extension of thecancer towards the pelvic sidewall.Stage IVStage IV cancers involve thebladder, rectum, lungs or other organs. 39
WHAT IS A CERVICAL CONIZATION?Conization: •Removes a cone-shaped piece of tissue •Often allows for diagnosis and treatment •Performed with local anesthesia in the office or under general anesthesia in the operating roomA cervical conization is often used todiagnose or exclude the presence of avery small cervical cancer. Thisprocedure is performed in the operatingroom with or without general anesthesiawhere a cone shaped segment of thecervix is removed.Alternatively a large cervical excisionalbiopsy can be performed in the officeunder local anesthesia.The risks associated with a cervical 40conization are bleeding, infection andinfertility.
WHAT IS A RADICAL HYSTERECTOMY??? Treatment option for early stage cancer Not the same as the usual hysterectomy Surgical removal of the uterus, cervix and upper vagina with the surrounding tissues Lymph nodes are removed Removal of the ovaries is not required If a hysterectomy must performed for the treatment of cervical cancer, a radical hysterectomy is usually performed. This involves removal of the uterus along with a portion of the surrounding support tissue and a portion of the upper vagina. The lymph nodes in the pelvis and sometimes those near the aorta are removed. The radical nature of the procedure results in a few more complications when compared to a simple hysterectomy. The most common changes are noted in the function of the bladder (you can’t tell when your bladder is full, so you must watch the clock to know when to go), shortening of the vagina and constipation. A radical hysterectomy does not require removal of the ovaries. 41
WHAT IS RADIATION WITHCHEMOTHERAPY (CHEMORADIATION)??? Standard of care for advanced cancer Treatment requires: 1. External radiation 2. Internal radiation 3. Low dose chemotherapy given at the same time For some women, treatment with chemoradiation is a better option than surgery. This is most often true with advanced cancer. Radiation is composed of two portions, external and internal radiation. A very low dose of chemotherapy is administered at the same time as the external radiation. This low dose of chemotherapy makes the radiation therapy more effective. External radiation is usually given in small doses five days a week for about five weeks. Fatigue, nausea, diarrhea, and skin or vaginal irritation are common side effects. For internal radiation, a radiation cylinder is placed inside the vagina where it delivers radiation treatment directly to the cervix. This procedure can last several hours to a full day in the hospital. Two to three treatments may be necessary. 42
CERVICAL CANCER: WHAT IS THE CHANCE OF SURVIVAL AFTER TREATMENT??? FIGO Stage 5-YearThe survival rate five yearsafter diagnosis varies Survivaldepending upon the stage of Stage I 81-96%cervical cancer. The riskincreases with higher stagesof disease. However, there Stage II 65-87%are treatment options foreveryone. Stage III 35-50% Stage IVA 15-20% 43
RE-ESTABLISHING WELLNESS… Restoring wellness is a gradual process Some women find strength from: Friends and family Support groups Spiritual work Counseling Exercise The challenges and the journey are different for each woman with cervical cancer 44
HOW DO I GET MY FRIENDS TO HAVE A PAPTEST??? Tell her it doesn’t hurt Offer her a ride Offer help with child care Help her get an appointment Help her find the right health care provider Empower her with information: Tell your friend about the importance of health prevention The most important thing that any woman can do to prevent cervical cancer is to have a Pap test regularly! It is very important to educate our friends about the importance of a Pap test. There are many reasons women postpone having a Pap test. Help your friend by reassuring her that a Pap test does not hurt. Give her a ride to get the Pap test. Offer to help with child care. Help her identify a health care provider or clinic so that she can make an appointment for her Pap test. 45
DOSES OF THE VACCINE… There are totally 3 doses Second dose is followed by the first dose after two months The third one is also vaccinated after two months from the second dose The third one is a bit painful but ignorable… 46
SOME PICTURES OF CERVICAL CANCER…. 47
CONTINUATION OF THE PICTURES…. 48
PICTURES OF HPV….. 49
THANK YOU FOR LOOKING INTO THISPPT….Take a vaccine andenjoy your life… THIS IS DONE BY: S.DHARSHINEE GOOD SHEPHERD INTERNATIONAL 50 DONE ON SCHOOL 26/6/2012
No woman should die of cervical cancer. The most important thing you can do to help prevent cervical cancer is to get screened regularly starting at age 21.
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