CERVICAL CANCER

A disease that can be prevented by

lifestyle changes and early
detection

PRESENTATION, 7TH YEAR ,DR

MWANZA
 Objectives
 Anatomy
 Definition
 Burden of disease
 Cause
 Risk factors
 Natural history
 Signs and symptoms
 Early detection
 Treatment options
 Anatomy

The cervix is the opening into the uterus (womb)

CANCER IS SIMILAR TO A
WEED WITH DEEP ROOTS
Abnormal Growth
A mass or overgrowth of
cells

Can be pre-cancerous or
cancerous

Underlying tissue
 Pre-Cancer vs. Cancer
Benign (not cancer) Cancerous (malignant)
tumor cells grow cells invade
only locally and cannot neighboring tissues,
spread by invasion or enter blood vessels,
metastasis and spread to different
sites

Time
 Burden of cervical cancer

 500,000 women/year are diagnosed

 250,000 women/year die

 80% of cancers and deaths occur in women who live in developing nations

 Number one cause of cancer and cancer-related death in sub-Saharan Africa

 Peaks at 35-45 years of age

 Zambia has second highest rates in the world, after Tanzania

 Rates are 5X’s higher in HIV-infected women

 Cause
Human Papillomavirus Infection
(HPV)

 Transmitted sexually (in most cases)

 80% eliminated by immune system within ~ 18
months, in most cases; 20% persist
 Risk factors for persistent HPV infection:
immunosuppression, smoking, nutritional
deficiencies, other unknown co-factors
 Women Most Likely To Get HPV
Infection

 Multiple sex partners

 Early onset of intercourse

 Natural history of cervical cancer

~20% within
10 years
60%
Low- High-
HPV Grade Grade Invasive
Infection 20% Pre-cancer Pre-cancer Cancer
(CIN 1) 10% in (CIN 2/3)
2 years
HPV infection
 CIN 1 (Low Grade Pre-Cancer)

Source: Photograph courtesy of Dr. Renzo Barrasso.

CIN 2 (High Grade Pre-Cancer)
CIN 3 (High Grade Pre-Cursor)
Suspicious for Cancer
Suspicious for Cancer
Suspicious for Cancer
Suspicious for Cancer
Suspicious for Cancer
 Signs and symptoms

 HPV and pre-cancer are asymptomatic

 Most common sign of invasion is abnormal

bleeding (post-coital)

 Back and leg pain, renal failure and fistulae are

late features
 Early detection and prevention

Invasive cervical cancer is preventable

 Primary prevention

 Secondary prevention
 Primary Prevention

Lifestyle changes to avoid HPV infection

• Delay onset of intercourse

• Limit number of sexual partners

• Don’t smoke

• Eat more fruits and vegetables

• Condoms

• HPV vaccine
 Secondary prevention

Screening

 Pap smear

 Visual Inspection with Acetic Acid (VIA)

What is a Pap Smear ?
Instrument Tray for VIA

Water Vinegar
What is Visual Inspection with Acetic Acid
(VIA)

Cervix smeared with

5% acetic acid
(vinegar)

Visualized after Examined for ‘Aceto-white’

Cervix visualized
1 min using 100 precancerous lesions (positive VIA
through speculum test) by trained personnel
watts lamp
VIA Positive
VIA Positive
VIA Positive
VIA Positive
VIA Positive
 Treatment

Pre-cancer

 Freeze it (Cryotherapy)

 Remove it (LEEP, Conization, Hysterectomy)

 Burn it (Laser)

Cure rate = 100%!!

 Cryotherapy Equipment Components
1. Probe
2. Trigger
10 3. Handle grip (fiberglass)
4. Yoke
1
2 5. Instrument inlet of gas
from cylinder
7 3
6. Tightening knob
7. Pressure gauge
showing cylinder
pressure
8. Silencer (outlet)
5 9 9. Gas-conveying tube
4 8
10. Probe tip
6

Source: Reprinted from Sellors and Sankaranarayanan,1 with permission.

Cryotherapy equipment
Cryoprobes

Source: Reprinted from Sellors and Sankaranarayanan,1 with permission.

 Cervix Immediately After
Cryotherapy

Source: Reprinted from Sellors and Sankaranarayanan,1 with permission.

 Cervix 2 Weeks After Cryotherapy

Source: Reprinted from Sellors and Sankaranarayanan,1 with permission.

 Cervix 3 Months After Cryotherapy

Source: Reprinted from Sellors and Sankaranarayanan,1 with permission.

 Smoke
evacuator
1. Tungsten wire loop, ball, and
2
macroneedle electrodes
2. Colposcope
3. Electrosurgical generator
4. Smoke evacuation system
3
5. Insulated Grave’s speculum with
smoke tube
1 6. Kogan’s endocervical speculum
4
7. Electrosurgical penholder
10 8. Insulated vaginal lateral wall
7 1
retractor
9. Tenaculum forceps
5 6 8
10. Cervical hook
9
 a b c d

(a) 20  8 mm semicircular loop electrode

(b) 10 mm square loop electrode
(c) Ball electrode
(d) Macroneedle-style electrode
 LEEP of an Ectocervical Lesion
With One Pass

Source: Reprinted from Sellors and Sankaranarayanan, 1 with permission.

Cervix Immediately After LEEP
 Cervix 3 Months After LEEP

Source: Reprinted from Sellors and Sankaranarayanan,1 with permission.

Cone Biopsy
 Cervix 3 Months After Cone Biopsy

Source: Reprinted from Sellors and Sankaranarayanan,1 with permission.

 Treatment
Invasive Cancer
 Simple hysteretomy
 Radical hysterectomy
 Radiation
 Chemo-radiation

Cure Rates
 Stage 1 - 90%
 Stage 2 - 70%
 Stage 3 - 40%
 Stage 4 - 10%
Bladder
Rectum
 Cytology Results

Suggestive of Normal
Cancer 6.21%
19.32%
ASCUS
17.22%

LSIL
HSIL 23.42%
33.83%
Cancer, There is Hope!
 Relative Proportion of HPV Genotypes
40

35

30

% o f to tal samp les

25

20

15

10

0
HPV types
52 61 62 58 53 84 35 81 16 45
71 51 31 66 CP6108 18 68 39 56 70
83 55 72 54 33 59 73 26 40 67
IS39 6 82 69 11 64
 ZAMBIAN CERVICAL CANCER
PREVENTION PROGRAM
 INITIATED 11/06
 4 CLINICS INTEGRATED WITHIN THE LUDH
- Matero Ref
- Chelstone
- Mtendere
- Kanyama
 SCREENED 800 WOMEN – 40% required treatment
 PLANS TO EXPAND
 Sensitivity and Specificity
 Sensitivity—percentage of women correctly
classified by the test as having CIN or cervical
cancer.
 Specificity—percentage of women correctly
classified by the test as not having CIN or
cervical cancer.
 Meta-Analysis of 11 African and
Indian Studies
 Pooled data from multiple cross-sectional studies
with 54,981 women, 25–65 years of age

Screening
test Sensitivity, % Specificity, %
VIA 76.8 85.5

Source: Data from Sankaranarayanan et al.14

 Visual Inspection with Acetic Acid (VIA)

VIA Category Clinical Findings

No acetowhite lesions or faint

acetowhite lesions; polyp,
Test-negative
cervicitis, inflammation, Nabothian
cysts.

Sharp, distinct, well-defined,

dense (opaque/dull or oyster
Test- white) acetowhite areas—with or
positive without raised margins touching
the squamocolumnar junction
(SCJ); leukoplakia and warts.

Suspicious for Clinically visible ulcerative,

cancer cauliflower-like growth or ulcer;
oozing and/or bleeding on touch.
 Early Detection
Pap Smear
 First Pap smear 3 years after onset of intercourse
or age 21, whichever comes first
 Conventional Pap smear
Annually (every year)
 Liquid-based Pap smear (Thin Prep)
Every 2 years
 After age 30, may consider Pap & HPV tests and
if both negative, can wait 3 years before next test
 When to Discontinue

 Atage 70 or older, if 3 or more consecutive

negative Pap test in last 10 years, may
consider discontinuing Pap test.
(Discuss with physician)
 After Hysterectomy

 Iftotal hysterectomy for benign reasons

(not cancer or pre-cancer) Pap test not
necessary

 Ifhysterectomy for cancer or pre-cancer or

reason unknown continue Pap test
 The Vagina

Uterus

Bladder Cervix
Posterior
Anterior fornix
fornix
Sacrum
Pubic Bone
Rectum
Urethra Vagina

Source: Reprinted from Sellors and Sankaranarayanan,1 with permission.

 Diagram of the TZ

Most Distal Cervical

TZ Crypt Opening

SCJ

{
Area of
Ectopy
 Internal Reproductive Organs

Fundus Fallopian
tube

Body of
uterus
Ovary

Internal os
External os Endocervical
canal/Ectocervix
Ectocervix Fornix

Vagina
External Cervical Os—Nulliparous
External Cervical Os—Parous
 Natural history of HPV infection
I
N
F
E
C First Immune About
T Response
Lesion 9 months Sustained
I
O clinical
N remission

Late
Active Growth Stage
Incubation (3–6 months)
(1–8 months) Host
Containment
(3–6 months)
Persistent or
recurrent
disease
 Natural History
of Cervical Cancer

10–15 years?

Basement Membrane

CIN 1 CIN 2 CIN 3 Invasive Cancer

 Pre-Cancer vs. Cancer
Benign (not cancer) Cancerous (malignant)
tumor cells grow cells invade
only locally and cannot neighboring tissues,
spread by invasion or enter blood vessels,
metastasis and spread to different
sites

Time
 Histology of Lesion Progression

CIN 1 CIN 2 CIN 3

 Classifying Cytologic Abnormalities

CIN 1 CIN 2 CIN 3 CIN 3

• Cell nuclei increase in density and size in comparison to the

cell cytoplasm.
• Cell and nuclear shapes become irregular.