prevention cervical cancer

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Prevention of Cervical Cancer Prof. Surendra Nath Panda, M.S. Dept. of Obstetrics and Gynecology M.K.C.G.Medical College Berhampur, Orissa, India

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Page 1: prevention Cervical cancer

Prevention of Cervical Cancer

Prof. Surendra Nath Panda, M.S.

Dept. of Obstetrics and Gynecology

M.K.C.G.Medical College

Berhampur, Orissa, India

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Prevention of Cervical Cancer - Prof. S.N.Panda 231-10-02

Cervical Cancer

• Cervical cancer is the third most common cancer worldwide

• 500,000 new cases identified each year

• 80% of the new cases occur in developing countries

• At least 200,000 women die of cervical cancer each year

Magnitude of the ProblemMagnitude of the Problem: -: -

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Prevention of Cervical Cancer - Prof. S.N.Panda 331-10-02

Cervical Cancer

• Cervical cancer is easily accessible to early diagnosis and treatment which can drastically reduce the mortality.

• More importantly, to a large extent Cervical More importantly, to a large extent Cervical cancer is a preventable disease*cancer is a preventable disease*

The irony of the ProblemThe irony of the Problem: -: -

*Please see notes page..

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Prevention of Cervical Cancer - Prof. S.N.Panda 431-10-02

Cervical Cancer

0

20

40

60

80

100

%

IA IB IIA IIB III

Stage

SCCAAdenoCA

from Grigsby, P.W., et.al Radiother Oncol 12:289, 1988from Grigsby, P.W., et.al Radiother Oncol 12:289, 1988

Five-Year Survival*: -Five-Year Survival*: -

*Please see notes page..

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Prevention of Cervical Cancer - Prof. S.N.Panda 531-10-02

Cervical Cancer

• HPV, HPV, HPV...– Women are generally infected with HPV in their teens,

20s, 30s – Cervical cancer can develop up to 20 years after HPV

infection

• Smoking

• Immunosuppressants

• Imbalance of Free radicals (+) & Antioxidants (-)

Risk FactorsRisk Factors: -: -

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Prevention of Cervical Cancer - Prof. S.N.Panda 631-10-02

Natural History of Cancer Cx.

Source: PATH 1997.

HPV-related Changes

Normal Cervix

Low-Grade SIL (Atypia, CIN I)

High-Grade SIL (CIN II, III/CIS)

Invasive Cancer

HPV Infection

CofactorsHigh-Risk HPV

(Types 16, 18, etc.)

About 60% regress within 2-3 yrs

About 15% progress within 3-4 yrs

30% - 70% progress within 10 yrs

Current Understanding: -Current Understanding: -

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Prevention of Cervical Cancer - Prof. S.N.Panda 731-10-02

PAP Smear Grade

Dysplasia CIN Histological Change

Bethesda

I Normal Normal Normal

II Inflammatory Inflammation ASCUS

III Mild CIN I Basal1/3 Low SIL

Moderate CIN II <Basal2/3 High SIL

Sever CIN III W .thickness

IV CIS

V SCC SCC SCC SCC

Natural History of Cancer Cx. Different Terminologies: -Different Terminologies: -

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Prevention of Cervical Cancer - Prof. S.N.Panda 831-10-02

Oster, A.G. IJGP 1993; 12: 186-192

No. of studies 17 12 21

No. pts 4,505 2,247 767

Regress 57% 43% 32%

Persist 32% 35% 56%

Progress to CIN 3 11% 22% 12%

Progress to Inv. Ca. 1% 5% 12%

Attribute Mild Moderate CIS

Natural History of Cancer Cx. Progression of Dysplasia: -Progression of Dysplasia: -

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Prevention of Cervical Cancer - Prof. S.N.Panda 931-10-02

Natural History of Cancer Cx.

• > 80% of CIN I & II regress by 10 yrs• about 10% of CIN I progress to CIS• about 20% of CIN II progress to CIS• about 5% of CIN I progress to invasive cancer• about 10% of CIN II progress to invasive cancer• about 50% of CIN III progress to invasive cancer• progression is a slow process

Summary of studies

Progression of Dysplasia: -Progression of Dysplasia: -

Page 10: prevention Cervical cancer

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Prevention of Cervical Cancer - Prof. S.N.Panda 1031-10-02

Prevention of Cervical Cancer

• Education to reduce high risk sexual behaviour.• Measures to reduce/avoid exposure to HPV and

other STIs.• Avoiding / minimising other risk factors, like early

marriage / child bearing, smoking• Administration of Antioxidants.• HPV vaccine (*Futuristic ?) –

– Prophylactic- antibody against capsid proteins L1, L2

– Therapeutic- antibody against E6 & E7

Strategies: -Strategies: - Primary prevention

*Please see notes page..

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Prevention of Cervical Cancer - Prof. S.N.Panda 1131-10-02

Prevention of Cervical Cancer

• DIAGNOSIS OF HPV INFECTION– Macroscopic– Cytological– HPV DNA testing by ultraspectrophotometry– Colposcopy– Histological

Strategies: -Strategies: - Primary prevention

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Prevention of Cervical Cancer - Prof. S.N.Panda 1231-10-02

Prevention of Cervical Cancer

• TREATMENT OF HPV INFECTION -No specific therapy.– Surgical removal– Local Ablation (See later): -

• Cryotherapy

• Diathermy

• Laser

– Administration of Interferon

Strategies: -Strategies: - Primary prevention

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Prevention of Cervical Cancer - Prof. S.N.Panda 1331-10-02

Prevention of Cervical Cancer

• Treatment of precancerous lesions before they progress to malignancy. which is simple, easy and effective.

• Key Point is “SCREENING” to detect precancerous lesions.

• Implies a good screening test, which is Effective, Safe, Practical, Affordable and easily Available.

Strategies: -Strategies: - Secondary prevention*

*Please see notes page..

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Prevention of Cervical Cancer - Prof. S.N.Panda 1431-10-02

Secondary Prevention

• PAP smear test is the gold standard – But has limitations*.

Screening for Pre malignant LesionsScreening for Pre malignant Lesions

*Please see notes page..

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Prevention of Cervical Cancer - Prof. S.N.Panda 1531-10-02

Secondary Prevention

• Visual inspection with acetic acid (VIA)• Visual inspection with acetic acid and

magnification (VIAM): Gynescope or Aviscope

• Colposcopy• Cervicography• Automated pap smears• Molecular (HPV/DNA) tests

Screening for Pre malignant LesionsScreening for Pre malignant LesionsOther Options: -

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Prevention of Cervical Cancer - Prof. S.N.Panda 1631-10-02

Source-Program for Appropriate Technology in Health [PATH] 1997.

Effective Safe Practical Affordable Available

Visual Inspection: AA

Yes Yes Yes Yes Yes

Visual Screening: Unaided

No Yes Yes Yes Yes

Automated Pap Screening

Yes? Yes ? No No

HPV Screening Yes Yes ? ? Yes

Cervicography Yes? Yes ? ? Yes

HPV Vaccine ? ? Yes ? No

Secondary Prevention

Alternatives to Pap Smear: -Alternatives to Pap Smear: -Screening for Pre malignant LesionsScreening for Pre malignant Lesions

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Prevention of Cervical Cancer - Prof. S.N.Panda 1731-10-02

Secondary Prevention

• WHOM TO SCREEN?– From - onset of sexual activity/adolescent

girl ( age of 18years) - to 65years.

• HOW FREQUENTLY? – Yearly.

– If Consecutive 2- 3 Smears are Negative, then at 3 - 5 years interval..

Screening for Pre malignant LesionsScreening for Pre malignant Lesions

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Prevention of Cervical Cancer - Prof. S.N.Panda 1831-10-02

Secondary Prevention

• Ideal and Desirable-Mass screening – – Conducted on whole population & is expensive.

• Selective screening – – Segment of population at high risk.

• Multiphalic screening – – Screening for several conditions in the same

sitting.

• Opportunistic screening – when patients are coming for other treatment-Very useful.

Types of ScreeningTypes of Screening

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Prevention of Cervical Cancer - Prof. S.N.Panda 1931-10-02

Secondary Prevention

• Colposcopy and biopsy

• Direct biopsy – Excisional / ?Multiple punch biopsy taken after application of Lugol’s iodine / Acetic acid on the cervix

• Cone biopsy with knife Laser.

• Endocervical Curettage along with Biopsy, a must in all cytology positive cases.

Diagnosis of CINDiagnosis of CIN

Regardless of severity, CIN generally is asymptomatic and not grossly visible on examination

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Prevention of Cervical Cancer - Prof. S.N.Panda 2031-10-02

Secondary PreventionTreatment of CIN- Multi optionsTreatment of CIN- Multi options

C I N I C I N II C I N III

Local Ablative / Destructive Procedures

Local Excisional Procedures

Hysterectomy + vaginal cuff

Cytology, Colposcopy & Biopsy reports must tally to perform Ablative / Excisional procedures.

Tissue removed at Excisional procedures must be studied again.

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Prevention of Cervical Cancer - Prof. S.N.Panda 2131-10-02

Secondary Prevention

• No Ablative procedure without histological confirmation of nature and grade of disease

• Preferably be done Under Colposcopy• Methods : -

– Cryosurgery-90% effective. – Electo surgical Fulguration/ Coagulation-90-95%

effective.– Co2 Laser ablation-90-97% effective.

Treatment of CIN I & IITreatment of CIN I & II

Local Destructive Procedures

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Prevention of Cervical Cancer - Prof. S.N.Panda 2231-10-02

Secondary Prevention

• Methods: -– Large Loop Excision of the Transformation Zone

(LLETZ) also known as Loop Electrosurgical Excision Procedure (LEEP)

– Therapeutic Conization– Cold Knife / Laser

• Cure rate: - 90-95 %.

• Advantage- Tissue is available for HP study.

Local Excisional Procedures

Treatment of CIN II & IIITreatment of CIN II & III

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Prevention of Cervical Cancer - Prof. S.N.Panda 2331-10-02

Secondary Prevention

• Hysterectomy without / with removal of vaginal cuff for: -– Women over 40– No further childbearing required– Women who do not want to come for follow up– Other associated pathology– Residual lesion after excisional procedures

• Vaginal route is preferable.• Ovaries need not be removed.

HysterectomyTreatment of CIN IIITreatment of CIN III

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Prevention of Cervical Cancer - Prof. S.N.Panda 2431-10-02

Secondary Prevention

• Women treated conservatively by Ablative or Excisional procedures have to be followed up regularly: -

• Criteria for cure: - Two consecutive normal PAP smears in follow up.

• First Visit - After 2-3 Months • Rest of the life – 3 yearly

– PAP smear at each visit– Avoid risk factors

Follow Up of CIN II & III Follow Up of CIN II & III

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Prevention of Cervical Cancer - Prof. S.N.Panda 2531-10-02

Conclusion

• Stage for stage, little progress has been made in lowering mortality rates from cervical cancer.

• However the overall mortality rate is decreasing because more patients are having their cancers diagnosed in early states of disease.

• The opportunity is there for all physicians to make an early diagnosis in Ca Cx and to protect the women from this dreadful disease.

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Prevention of Cervical Cancer - Prof. S.N.Panda 2631-10-02

Conclusion

• *But more importantly, all attempts should be made to prevent the occurrence of the disease in the first place, – by screening for precancerous lesions and

– effectively treating them, by methods which are very safe, simple and easy.

• “Prevention better than cure” - Never more True• Those women saved from the ravages of cervical

cancer shall call their physicians blessed.

*Please see notes page..

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Prevention of Cervical Cancer - Prof. S.N.Panda 2731-10-02

Thank YouThank You

At the service of women