CERVICAL CANCER
Cervical cancer is the most common female malignancy in Africa, Asia, and
South America
Cervical cancer is the second most common female malignancy in the world
Cervical cancer is the eighth most common female malignancy in the US due
to the availability of PAP smear
Most common cause of female cancer death worldwide
13,000 new cases in US annually
7,000 deaths in US annually
mean age = 52.2 years
PAP SMEARS
Periodic screening with PAP smears seems to be the only way to effectively
improve survival rates
Developed in 1940’s by George Papanicolau
Greatest risk begins with the onset of sexual activity
Perform PAP smears annually for the at-risk population
May perform at 3-yr intervals after 3 normal smears and no change in risk
mass screening program developed in British Columbia in 1950.
Incidence: 1954, 25/100,000 women
1984, 8/100,000 women
Death Rate: 1962, 13/100,000 women
1983, 3/100,000 women
OBTAINING THE BEST PAP
Do not douche, wash the vagina or have intercourse 24hrs before the exam
Do not test during menses or less than one week after stopping vaginal
medications
Pap should be taken before the manual exam
A sample of the outer cervix and the cervical canal is taken
CURRENT RECOMMENDATIONS FOR PAP SMEAR SCREENING
Start at age 18 or when sexual activity begins
Perform annually
Continue annually for at least 3 years if normal
May then perform at 3 year intervals if sexual relationship is unchanged
ACCURACY OF PAP SMEARS
Extremely accurate if high grade lesions are found
May overdiagnose low grade lesions
False negatives may range from 8-50%
Even with a test that may have a 20% false negative rate, PAP smears reduce
the risk of death from cervical cancer
It takes 10-17 yrs to possibly develop cancer from a low grade lesion
It takes 5-10 yrs to possibly develop cancer from high grade lesion
MY PAP SMEAR IS ABNORMAL, NOW WHAT???
Don’t panic – most PAP smear abnormalities do not reveal cancer
The evaluation is not an emergency. You should be seen within a couple of
weeks
Remember that a PAP is a screening test, not a diagnosis
Colposcopy allows your physician to evaluate the cervix and vagina and
establish the correct diagnosis
PAP SMEAR REPORT
Class World Health Organization System Bethesda System
I normal within normal limits
II atypical ASCUS)benign cellular change
III dysplasia squamous cell lesions
IV carcinoma in situ HGSIL
V invasive cancer Cancer
COLPOSCOPY
Essentially a means of visualizing the cervix and vagina with
magnification
Magnification allows the evaluation of blood vessel and tissue thickness
patterns which correlate with the type of cells seen on the PAP smear
Small biopsies may be taken through areas that are felt to be
representative of the abnormality suspected
The physician should be able to give a fairly accurate prediction of the
pathology which will be found on the actual biopsies
VIRAL NATURE OF CERVICAL CANCER
Cervical cancer is frequent among prostitutes
Cervical cancer is rare among adult virgins
Cervical cancer is often found in women with other venereal diseases
Marriage to a male whose former partner had cervical cancer increases
risk by 2-3 times
HPV is sexually transmitted
Cervical cancer appears to be sexually transmitted
Cervical cancer is more common among women starting coitus earlier,
having more sexual partners and greater sexual frequency
HPV (HUMAN PAPILLOMA VIRUS)
40% of women with normal pap smears may have laboratory evidence of this
virus, thus the majority of women with the virus will have normal pap smears
sexually active younger women have higher prevalency rates than their
nonsexual cohorts
HPV 6,11 is most commonly transmitted but does not lead to high cancer
probability
HPV 16,18 is less commonly transmitted but does lead to high cancer
probability
46% women in student health service tested positive for HPV
30% of the study group had oncogenic virus
approximately 40% of asymptomatic women have virus
thought to be sexually transmitted since the Greeks and Romans
60% of sexual partners of patients with warts get warts
spread through intimate contact – does not require intercourse
infectivity rate of 60%
highly contagious
65% of male partners of women with subclinical lesions have HPV
associated penile lesions
Having the virus does not mean you have warts, but having warts means
that you have the virus
HPV EXPOSURE
No lesion
Latent lesion
Obvious clinical lesion
HPV INCUBATION
Incubation period ranges from 3 weeks to 8 months (average 2.3 months)
Viral replication and wart growth usually starts 3-6 months after
exposure
HPV IS COMMON, BUT…
Only 10% of infections lead to warts of dysplasia
Less than 1% of women with HPV will develop cancer
Development of dyplastic of malignant lesions may require an additional
co-factor
PREVENTING HPV
Remain celibate
Choose partner wisely but remember that many have latent infection and
will honestly state that they "have never had anything"
Don’t touch anything that is not covered by a glove, condom, or body
armor
IN REALITY
While there is no cure for HPV, it is not that difficult to deal with the
lesions should they occur
Cervical cancer takes time to develop
High grade lesions have a 30% risk of cancer in 10-15 yrs
The best defense for any serious effect of HPV is a routine PAP smear
Many women with HPV are overtreated, not undertreated
Surgery cannot get rid of a virus that lives well on a variety of
membrane and skin surfaces
SYMPTOMS OF CERVICAL CANCER
Vaginal, generally postcoital bleeding
Foul smelling vaginal discharge
Weight loss
Kidney obstruction
DIAGNOSIS OF CERVICAL CANCER
PAP smear screening
Colposcopy
Biopsy: in office, or cone biopsy as outpatient
PATTERNS OF SPREAD OF CERVICAL CANCER
Direct invasion of cervix, uterus, and other pelvic structures
Lymphatic spread (directly relates to stage of disease)
Blood-born metastasis
STAGES OF CERVICAL CANCER
Stage 0 = carcinoma in situ
Stage I = cancer confined to cervix
Stage II = cancer outside of cervix
Stage III = outside of cervix to side of pelvis
Stage IV = outside of pelvis or into bladder or rectum
TREATMENT OF CERVICAL CANCER
Stage dependent
Surgery for pre-invasive disease: cryotherapy, leep, cone biopsy
Radical hysterectomy or radiation for early invasive disease
Radiation therapy + chemotherapy for advanced disease limited to pelvis
Chemotherapy for distant disease is never curative – chemo only slows
progress of disease
Radiation, exenteration, chemotherapy for recurrence
SURVIVAL FROM CERVICAL CANCER
Lymph node status
90% 5 year survival if nodes negative
20-60% 5 year survival if positive
Tumor size
90% if <2 cm
60% if >2 cm
Spread
95% if confined to cervix
60% if outside cervix
ENDOMETRIAL CARCINOMA
Most common gyn malignancy in US
34,000 new cases per year
3,000 deaths per year
Risks are obesity, affluence, and low parity
7.38/1000 white women
5.4/1000 nonwhite women
SYMPTOMS OF ENDOMETRIAL CARCINOMA
Postmenopausal bleeding
Enlarged uterus with infectious type of drainage
Physical examination is generally normal
WOMEN AT RISK FOR ENDOMETRIAL CANCER
Postmenopausal, on estrogens
Obese
Family history of breast, colon, ovarian, and endometrial cancers
Menopause starting after 52 yrs
Nonovulating, premenopausal
DIAGNOSIS OF UTERINE CANCER
Diagnosis almost always made by direct biopsy of the uterine cavity
Ultrasound is sometimes helpful if it shows a thickened uterine wall
Hysteroscopy allows direct visualization of the uterine cavity
SPREAD OF UTERINE CANCER
Direct extension to nearby structures
Cancer cells may move through the fallopian tubes
Lymphatic spread
Hematogenous spread to lungs, liver, brain, and bone
STAGES OF UTERINE CANCER
Stage I = confined to upper uterus
Stage II = involves upper uterus and cervix
Stage III = spread beyond uterus, but not outside the pelvis
Stage IV = spread beyond pelvis
TREATMENT OF UTERINE CANCER
Stage I = hysterectomy and removal of ovaries
Stage II = radical hysterectomy or radiation with hysterectomy
Stage III = radiation therapy
Stage IV = surgery/radiation/chemo
PROGNOSTIC VARIABLES OF UTERINE CANCER
Age
Cell type
Cell grade: differentiation. Well-differentiated cells have a 90% 5-yr
survival rate. Poorly differentiated cells have a greater risk of developing
recurrent disease.
Invasion into uterine wall
Cells in the abdominal cavity
UTERINE CANCER SURVIVAL
Stage I = 75%
Stage II = 58%
Stage III = 30%
Stage IV = 11%
OVARIAN CANCER
19,000 new cases per year in US
12,000 deaths per year
highest death rate of gyn malignancies
EPIDEMIOLOGY OF OVARIAN CANCER
Peak onset at age 64
Uncommon before age 50
Less than 1% occur before age 30
30% of ovarian tumors in postmenopausal women are malignant
7% of tumors in premenopausal women are malignant
SIGNS AND SYMPTOMS OF OVARIAN CANCER
May be quite vague
Pelvic pressure or general discomfort
Poor appetite, taste changes, belching, distended abdomen
Pain is unusual
Pelvic exam usually abnormal
OVARIAN CANCER SCREENING
Essentially there is no screening test available
CA 125 – protein product made by some ovarian cancers. Tumor marker used
for following progress or digression of ovarian cancer. CA 125 test lacks
sensitivity and specificity
CA 125 AND ultrasound can be considered if there is a strong family history
TYPES OF OVARIAN CANCER
Epithelial
75% serous
20% mucinous
2% endometriod, clear cell, Brenner
Germ Cell
Dysgerminoma
Teratoma
Yolk Sac
Gonadal Stromal
Granulosa Cell
STAGES OF OVARIAN CANCER
Stage I = confined to the ovaries
Stage II = beyond ovaries but limited to pelvis
Stage III = confined to abdomen
Stage IV = outside the abdomen
SPREAD OF OVARIAN CANCER
Implantation on surfaces of the abdominal cavity
Lymphatic
Hematogenous – uncommon
75% are Stage III at time of diagnosis
TREATMENT OF OVARIAN CANCER
First step is always surgery: remove uterus, ovaries, omentum, and attempt
to minimize disease. Removing ovaries reduces risk but does not eliminate risk
of regrowth.
Unless tumor is confined to ovary, chemo is required
Optimal initial surgery is critical
IMPORTANCE OF SURGERY
Residual tumor >15mm = 6 month median survival
Residual tumor >5-15 mm = 18 month median survival
Residual tumor < 5 mm = 40 month median survival
CHEMOTHERAPY FOR OVARIAN CANCER
Most commonly involves Cisplatinum, Carboplatinum, and Taxol
Generally given IV every 3 weeks
Side effects are depression of WBC, hair loss, nausea, neuropathy, possible
kidney damage
OVARIAN CANCER 5 YR SURVIVAL RATES
Age <50 = 40% >50 = 15%
Stage I = 80% Stage III = 5%
Stage II = 30-40% Stage IV = 5%
Residual Disease:
Microscopic = 40-75%
<1cm = 30-40% >1cm = 5%