Prevention of Cervical Cancer Prof. Surendra Nath Panda, M.S. Dept. of Obstetrics and Gynecology M.K.C.G.Medical College ...
Cervical Cancer <ul><li>Cervical cancer is the third most common cancer worldwide </li></ul><ul><li>500,000 new cases iden...
Cervical Cancer <ul><li>Cervical cancer is easily accessible to early diagnosis and treatment which can drastically reduce...
Cervical Cancer from Grigsby, P.W., et.al Radiother Oncol 12:289, 1988 Five-Year Survival*: - *Please see notes page..
Cervical Cancer <ul><li>HPV, HPV, HPV... </li></ul><ul><ul><li>Women are generally infected with HPV in their teens, 20s, ...
Natural History of Cancer Cx. Source : PATH 1997. Current Understanding: - HPV-related Changes Normal Cervix Low-Grade SI...
Natural History of Cancer Cx. Different Terminologies: - <Basal2/3 CIN II Moderate III Low SIL Basal1/3 CIN I Mild CIN II...
Natural History of Cancer Cx. Oster, A.G. IJGP 1993; 12: 186-192 Progression of Dysplasia: - No. of studies 17 12 2...
Natural History of Cancer Cx. <ul><li>> 80% of CIN I & II regress by 10 yrs </li></ul><ul><li>about 10% of CIN I progress...
Prevention of Cervical Cancer <ul><li>Education to reduce high risk sexual behaviour. </li></ul><ul><li>Measures to reduce...
Prevention of Cervical Cancer <ul><li>DIAGNOSIS OF HPV INFECTION </li></ul><ul><ul><li>Macroscopic </li></ul></ul><ul><ul>...
Prevention of Cervical Cancer <ul><li>TREATMENT OF HPV INFECTION -No specific therapy. </li></ul><ul><ul><li>Surgical remo...
Prevention of Cervical Cancer <ul><li>Treatment of precancerous lesions before they progress to malignancy. which is simpl...
Secondary Prevention <ul><li>PAP smear test is the gold standard – But has limitations*. </li></ul>Screening for Pre mali...
Secondary Prevention <ul><li>Visual inspection with acetic acid (VIA) </li></ul><ul><li>Visual inspection with acetic acid...
Secondary Prevention Source-Program for Appropriate Technology in Health [PATH] 1997. Alternatives to Pap Smear: - Screen...
Secondary Prevention <ul><li>WHOM TO SCREEN? </li></ul><ul><ul><li>From - onset of sexual activity/adolescent girl ( age o...
Secondary Prevention <ul><li>Ideal and Desirable-Mass screening – </li></ul><ul><ul><li>Conducted on whole population & i...
Secondary Prevention <ul><li>Colposcopy and biopsy </li></ul><ul><li>Direct biopsy – Excisional / ?Multiple punch biopsy t...
Secondary Prevention Treatment of CIN- Multi options C I N I C I N II C I N III Local Ablative / Destructive Procedures Lo...
Secondary Prevention <ul><li>No Ablative procedure without histological confirmation of nature and grade of disease </li><...
Secondary Prevention <ul><li>Methods: - </li></ul><ul><ul><li>Large Loop Excision of the Transformation Zone (LLETZ) also ...
Secondary Prevention <ul><li>Hysterectomy without / with removal of vaginal cuff for: - </li></ul><ul><ul><li>Women over ...
Secondary Prevention <ul><li>Women treated conservatively by Ablative or Excisional procedures have to be followed up reg...
Conclusion <ul><li>Stage for stage, little progress has been made in lowering mortality rates from cervical cancer. </li><...
Conclusion <ul><li>*But more importantly, all attempts should be made to prevent the occurrence of the disease in the firs...
Thank You  At the service of women
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prevention Cervical cancer

Published on: Mar 4, 2016
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Transcripts - prevention Cervical cancer

  • 1. Prevention of Cervical Cancer Prof. Surendra Nath Panda, M.S. Dept. of Obstetrics and Gynecology M.K.C.G.Medical College Berhampur, Orissa, India
  • 2. Cervical Cancer <ul><li>Cervical cancer is the third most common cancer worldwide </li></ul><ul><li>500,000 new cases identified each year </li></ul><ul><li>80% of the new cases occur in developing countries </li></ul><ul><li>At least 200,000 women die of cervical cancer each year </li></ul>Magnitude of the Problem : -
  • 3. Cervical Cancer <ul><li>Cervical cancer is easily accessible to early diagnosis and treatment which can drastically reduce the mortality. </li></ul><ul><li>More importantly, to a large extent Cervical cancer is a preventable disease* </li></ul>The irony of the Problem : - *Please see notes page..
  • 4. Cervical Cancer from Grigsby, P.W., et.al Radiother Oncol 12:289, 1988 Five-Year Survival*: - *Please see notes page..
  • 5. Cervical Cancer <ul><li>HPV, HPV, HPV... </li></ul><ul><ul><li>Women are generally infected with HPV in their teens, 20s, 30s </li></ul></ul><ul><ul><li>Cervical cancer can develop up to 20 years after HPV infection </li></ul></ul><ul><li>Smoking </li></ul><ul><li>Immunosuppressants </li></ul><ul><li>Imbalance of Free radicals (+) & Antioxidants (-) </li></ul>Risk Factors : -
  • 6. Natural History of Cancer Cx. Source : PATH 1997. Current Understanding: - HPV-related Changes Normal Cervix Low-Grade SIL (Atypia, CIN I) High-Grade SIL (CIN II, III/CIS) Invasive Cancer HPV Infection Cofactors High-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
  • 7. Natural History of Cancer Cx. Different Terminologies: - <Basal2/3 CIN II Moderate III Low SIL Basal1/3 CIN I Mild CIN III Sever High SIL SCC SCC SCC SCC V W .thickness CIS IV ASCUS Inflammation Inflammatory II Normal Normal Normal I Bethesda Histological Change CIN Dysplasia PAP Smear Grade
  • 8. Natural History of Cancer Cx. Oster, A.G. IJGP 1993; 12: 186-192 Progression of Dysplasia: - 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
  • 9. Natural History of Cancer Cx. <ul><li>> 80% of CIN I & II regress by 10 yrs </li></ul><ul><li>about 10% of CIN I progress to CIS </li></ul><ul><li>about 20% of CIN II progress to CIS </li></ul><ul><li>about 5% of CIN I progress to invasive cancer </li></ul><ul><li>about 10% of CIN II progress to invasive cancer </li></ul><ul><li>about 50% of CIN III progress to invasive cancer </li></ul><ul><li>progression is a slow process </li></ul>Summary of studies Progression of Dysplasia: -
  • 10. Prevention of Cervical Cancer <ul><li>Education to reduce high risk sexual behaviour. </li></ul><ul><li>Measures to reduce/avoid exposure to HPV and other STIs. </li></ul><ul><li>Avoiding / minimising other risk factors, like early marriage / child bearing, smoking </li></ul><ul><li>Administration of Antioxidants. </li></ul><ul><li>HPV vaccine (*Futuristic ?) – </li></ul><ul><ul><li>Prophylactic- antibody against capsid proteins L1, L2 </li></ul></ul><ul><ul><li>Therapeutic- antibody against E6 & E7 </li></ul></ul>Strategies: - Primary prevention *Please see notes page..
  • 11. Prevention of Cervical Cancer <ul><li>DIAGNOSIS OF HPV INFECTION </li></ul><ul><ul><li>Macroscopic </li></ul></ul><ul><ul><li>Cytological </li></ul></ul><ul><ul><li>HPV DNA testing by ultraspectrophotometry </li></ul></ul><ul><ul><li>Colposcopy </li></ul></ul><ul><ul><li>Histological </li></ul></ul>Strategies: - Primary prevention
  • 12. Prevention of Cervical Cancer <ul><li>TREATMENT OF HPV INFECTION -No specific therapy. </li></ul><ul><ul><li>Surgical removal </li></ul></ul><ul><ul><li>Local Ablation (See later): - </li></ul></ul><ul><ul><ul><li>Cryotherapy </li></ul></ul></ul><ul><ul><ul><li>Diathermy </li></ul></ul></ul><ul><ul><ul><li>Laser </li></ul></ul></ul><ul><ul><li>Administration of Interferon </li></ul></ul>Strategies: - Primary prevention
  • 13. Prevention of Cervical Cancer <ul><li>Treatment of precancerous lesions before they progress to malignancy. which is simple, easy and effective. </li></ul><ul><li>Key Point is “SCREENING” to detect precancerous lesions. </li></ul><ul><li>Implies a good screening test, which is Effective, Safe, Practical, Affordable and easily Available. </li></ul>Strategies: - Secondary prevention* *Please see notes page..
  • 14. Secondary Prevention <ul><li>PAP smear test is the gold standard – But has limitations*. </li></ul>Screening for Pre malignant Lesions *Please see notes page..
  • 15. Secondary Prevention <ul><li>Visual inspection with acetic acid (VIA) </li></ul><ul><li>Visual inspection with acetic acid and magnification (VIAM): Gynescope or Aviscope </li></ul><ul><li>Colposcopy </li></ul><ul><li>Cervicography </li></ul><ul><li>Automated pap smears </li></ul><ul><li>Molecular (HPV/DNA) tests </li></ul>Screening for Pre malignant Lesions Other Options: -
  • 16. Secondary Prevention Source-Program for Appropriate Technology in Health [PATH] 1997. Alternatives to Pap Smear: - Screening for Pre malignant Lesions
  • 17. Secondary Prevention <ul><li>WHOM TO SCREEN? </li></ul><ul><ul><li>From - onset of sexual activity/adolescent girl ( age of 18years) - to 65years. </li></ul></ul><ul><li>HOW FREQUENTLY? </li></ul><ul><ul><li>Yearly. </li></ul></ul><ul><ul><li>If Consecutive 2- 3 Smears are Negative, then at 3 - 5 years interval.. </li></ul></ul>Screening for Pre malignant Lesions
  • 18. Secondary Prevention <ul><li>Ideal and Desirable-Mass screening – </li></ul><ul><ul><li>Conducted on whole population & is expensive. </li></ul></ul><ul><li>Selective screening – </li></ul><ul><ul><li>Segment of population at high risk. </li></ul></ul><ul><li>Multiphalic screening – </li></ul><ul><ul><li>Screening for several conditions in the same sitting. </li></ul></ul><ul><li>Opportunistic screening – when patients are coming for other treatment-Very useful. </li></ul>Types of Screening
  • 19. Secondary Prevention <ul><li>Colposcopy and biopsy </li></ul><ul><li>Direct biopsy – Excisional / ?Multiple punch biopsy taken after application of Lugol’s iodine / Acetic acid on the cervix </li></ul><ul><li>Cone biopsy with knife Laser. </li></ul><ul><li>Endocervical Curettage along with Biopsy, a must in all cytology positive cases. </li></ul>Diagnosis of CIN Regardless of severity, CIN generally is asymptomatic and not grossly visible on examination
  • 20. Secondary Prevention Treatment 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.
  • 21. Secondary Prevention <ul><li>No Ablative procedure without histological confirmation of nature and grade of disease </li></ul><ul><li>Preferably be done Under Colposcopy </li></ul><ul><li>Methods : - </li></ul><ul><ul><li>Cryosurgery-90% effective. </li></ul></ul><ul><ul><li>Electo surgical Fulguration/ Coagulation-90-95% effective. </li></ul></ul><ul><ul><li>Co2 Laser ablation-90-97% effective. </li></ul></ul>Treatment of CIN I & II Local Destructive Procedures
  • 22. Secondary Prevention <ul><li>Methods: - </li></ul><ul><ul><li>Large Loop Excision of the Transformation Zone (LLETZ) also known as Loop Electrosurgical Excision Procedure (LEEP) </li></ul></ul><ul><ul><li>Therapeutic Conization– Cold Knife / Laser </li></ul></ul><ul><li>Cure rate: - 90-95 %. </li></ul><ul><li>Advantage- Tissue is available for HP study. </li></ul>Local Excisional Procedures Treatment of CIN II & III
  • 23. Secondary Prevention <ul><li>Hysterectomy without / with removal of vaginal cuff for: - </li></ul><ul><ul><li>Women over 40 </li></ul></ul><ul><ul><li>No further childbearing required </li></ul></ul><ul><ul><li>Women who do not want to come for follow up </li></ul></ul><ul><ul><li>Other associated pathology </li></ul></ul><ul><ul><li>Residual lesion after excisional procedures </li></ul></ul><ul><li>Vaginal route is preferable. </li></ul><ul><li>Ovaries need not be removed. </li></ul>Hysterectomy Treatment of CIN III
  • 24. Secondary Prevention <ul><li>Women treated conservatively by Ablative or Excisional procedures have to be followed up regularly: - </li></ul><ul><li>Criteria for cure: - Two consecutive normal PAP smears in follow up. </li></ul><ul><li>First Visit - After 2-3 Months </li></ul><ul><li>Rest of the life – 3 yearly </li></ul><ul><ul><li>PAP smear at each visit </li></ul></ul><ul><ul><li>Avoid risk factors </li></ul></ul>Follow Up of CIN II & III
  • 25. Conclusion <ul><li>Stage for stage, little progress has been made in lowering mortality rates from cervical cancer. </li></ul><ul><li>However the overall mortality rate is decreasing because more patients are having their cancers diagnosed in early states of disease. </li></ul><ul><li>The opportunity is there for all physicians to make an early diagnosis in Ca Cx and to protect the women from this dreadful disease. </li></ul>
  • 26. Conclusion <ul><li>*But more importantly, all attempts should be made to prevent the occurrence of the disease in the first place, </li></ul><ul><ul><li>by screening for precancerous lesions and </li></ul></ul><ul><ul><li>effectively treating them, by methods which are very safe, simple and easy. </li></ul></ul><ul><li>“ Prevention better than cure” - Never more True </li></ul><ul><li>Those women saved from the ravages of cervical cancer shall call their physicians blessed. </li></ul>*Please see notes page..
  • 27. Thank You  At the service of women

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