Screening Premalignant

Conditions in
Gynecology
Ahella Jastanyah 1707256
Reema Alzahrani 1706442
 Objectives

By the end of this presentation, you’ll be able to:

1. Describe the epidemiology of cervical cancer and its risk factors.

2. Explore the interplay between HPV and the cervical transformation zone (TZ) in the pathogenesis of
cervical malignancy.
3. Review the current strategy for prevention and screening of cervical cancer.
4. Outline the approach to a patient with an abnormal Papanicolaou (PAP) smear.
5. Describe Premalignant disease of the cervix and current management.
6. List the different types, clinical picture and FIGO staging of cervical cancer.
7. Outline the management and prognosis of cervical cancer according to its stage.
8. Appreciate how early detection improves the prognosis (5-year survival).
9. A woman presents with an abnormal PAP result. How are you going to counsel her?
10. She doesn’t follow the screening program and presents later with cervical cancer.
11. Break the news of cancer diagnosis to this woman
 Epidemiology
of cervical cancer

Third most common cancer in women worldwide

13,000 new cases diagnosed annually in the United
States, leading to an estimate of 4,100 deaths.

HPV Type 16 & 18 account for 70% of cervical cancer

80% of HPV infection outcome leads to recovery,
whereas only 1% predisposes to malignancy.

Mean age of incidence is 47 years

It is usually diagnosed between ages of 35 and 55.

Rare before the age of 25.

 Prevalence in Saudi arabia

Cervical Cancer reported

incidence is low in Saudi Arabia,
ranking number 12 between all
cancers in Saudi females.

It accounts only for 2.4% of all

new cases.
 Risk Factors

1
Young age at first coitus (<17)
4 High parity

Young age at first

2 Multiple sexual partners
or partners of partner
5 pregnancy

Young age at first

3 Young age at first
pregnancy 6 pregnancy
 Pathogenesis of
cervical cancer

The transformation zone constantly undergo a process of squamous metaplasia, in which

cervical columnar epithelium changes into squamous cells during periods of endocrine
change. It is a physiologic process in normal situation but when it corresponds with an HPV
infection, alterations of cells may then result into an atypical transformation zone.

These atypical changes start a cervical intraepithelial neoplasia which is the preinvasive
phase of cervical cancer.
 Prevention

Primary • Quadrivalent vaccine Gardasil

• Bivalent vaccine Cervarix

Prevention
Vaccines are most effective if taken before
the onset of sexual activity

Secondary
Prevention
Papanicolaou (Pap) smear

Within 3 years of sexual intercourse

 Screening

The American College of Obstetricians and Gynecologists (ACOG) has recommended that all women
should undergo an annual physical examination, including a Papanicolaou (Pap) smear, within 3 years of
sexual intercourse, or by age 21.
There’s a chance of false-negative rate of 20%, yet newer technologies have emerged for more accurate
results, including:

Thin Prep (Cytyc Corporation)

Surepath (TriPath Imaging)

Which are automated liquid-based slide-preparation systems,

pap smear brush is used to take the specimen then it is placed in a liquid in which blood and mucus are
cleared.
Then Focal Point (Surepath) and ThinPrep Imager (Cytyc) computerized image processors select the
most abnormal cells on a slide yielding a more sensitive cytologic testing.
 Cervical
Intraepithelial
Neoplasia
Cervical Intraepithelial
Neoplasia
Its in an abnormal epithelial proliferation
above the basement membrane. It forms
a spectrum of severity, in which if
involvement of the inner one-third of the
epithelium represents LSIL. Whereas e
involvement of the outer two-thirds
represents HSIL

Superficial ablative techniques like:
Large loop excision
Of transformational zone
Cheap
Can be done in OPD
under local anesthesia
Tissue is taken to be
histologically tested
TREATMENT of CIN
Carbon Dioxide laser
Cryosurgery
Destruction of Tzone
Useful for lesions
Expensive involving 1 or 2
quadrants but has a
Can be done in OPD under high chance of failure if
loacal anesthesia the lesion was larger or
if it extends to the
glandular crypts
 TREATMENT of CIN

Superficial ablative techniques like:

Large loop excision Carbon Dioxide laser
Cryosurgery
Of transformational zone Destruction of Tzone
Invasive
Cancer
 Clinical Features

1 Cervix may be
Postcoital, intermenstrual, or
postmenopausal bleeding. 4 ulcerative or exophytic

Incontinence due to
2 Persistent vaginal discharge.
5 fistula formation

3 Pelvic pain
6 Weight loss
 Types of Cervical Cancer

Squamous Cell
Carcinoma Adenocarcinoma
● Most common type of cervical cancers. ● Accounts for 20-25% of cervical cancers
Stages

INTERNATIONAL FEDERATION OF
GYNECOLOGY AND OBSTETRICS
STAGING OF CARCINOMA OF THE
CERVIX UTERI (2009)
 Treatment of
invasive cervical cancer
according to FIGO
staging system
Stage IA1

Surgery:
● Conization in patients who wish to conceive
OR
● Simple extrafascial hysterectomy without lymphadenectomy
-If fertility is not a factor (Patients who do not wish to conceive)
-If the tumor cannot be completely removed by conization

Radiation/Chemotherapy:
Primary radiotherapy in patients for whom surgery is not an option (ex: severe cardiac, pulmonary, or renal disease)
Stage IA2

Surgery:
● Modified radical hysterectomy and bilateral
pelvic lymphadenectomy
OR
● Conization or radical trachelectomy with bilateral pelvic lymphadenectomy in patients who wish to conceive

Radiation/Chemotherapy:
● Intracavitary radiation therapy
OR
● Concurrent chemoradiation (without surgery)
Stage IB–IIA

Surgery:
● Modified radical hysterectomy with bilateral pelvic lymphadenectomy
OR
● Radical trachelectomy with bilateral pelvic
lymphadenectomy in patients who wish to conceive

Radiation/Chemotherapy:
Concurrent chemoradiation
Stage IIB–III

● Surgery:
Adjuvant hysterectomy may be considered after chemoradiation

● Radiation/Chemotherapy:
Concurrent chemoradiation
Stage IVA

Surgery:
● Adjuvant radical hysterectomy with bilateral pelvic lymphadenectomy with or without paraaortic lymphadenectomy may be considered after chemoradiation

Radiation/Chemotherapy:
● Concurrent chemoradiation (preferred treatment option)
OR
● Neoadjuvant chemotherapy
OR
● Interstitial brachytherapy
Stage IVB

Surgery:
● Adjuvant hysterectomy may be considered after chemoradiation
● Pelvic exenteration may be considered after radiotherapy alone

Radiation/Chemotherapy:
● Palliative concurrent chemoradiation
OR
● Palliative chemotherapy and targeted therapy (e.g., bevacizumab)
OR
● Palliative radiation therapy
Prognosis
Prognosis

Cervical cancer has the best prognosis out of the three main gynecological cancers
(ovarian, endometrial, and cervical cancer).

The survival rates decrease with increasing FIGO stage

Stage I: 93%
Stage II: 63%
Stage III: 35%
Stage IV: 16%

Patients without lymph node involvement have a very good prognosis, regardless of FIGO
stage.
How to counsel women
with an abnormal Pap
smear?
 Counseling Tips
First rule: ask probing questions :

Questions that are specific to HER

What does she “know”

About HER
concerns, questions, and
feelings
Talking Points
● Your screening test result is positive but that does not mean you have cervical cancer.

● It means that you have a few cells in the cervix that are not normal.

● These abnormal cells may simply be the result of infection by the virus (HPV) causing
cervical cancer.

● Very few women with this virus infection will have cervical pre-cancer or cancer.

● In a small number of women, these abnormal cells may produce early changes in the cervix
(pre-cancers), that can easily be detected and treated.
Talking Points
● In view of your positive test result, you will either receive appropriate treatment
or will be referred for further check up.

● If you are advised treatment, please do not worry. Treatment takes very little
time, is not painful and you can go home on the same day.

● Keep your screening/treatment records safely and carry them along with you
every time you visit your health care facility for check- ups.
 Breaking
bad news to a cancer patient
When breaking bad news, do so privately and without
interruptions.

o Use the ABCDE technique

 ABCDE technique

1. Advanced preparation

- Be familiar with relevant with clinical information

– Be prepared to discuss basics of treatment and prognosis.

2. Build a therapeutic environment and relationship.

- Have family support present; meet everyone.

- Warm the bad news is coming.
- Eye contact appropriately touch personal closeness are important. (If possibly set
with the patient on the bed or at the bedside and hold his / her hand or touch the
forearm).
 ABCDE technique

3. Communicate well:

Ask the patient what they think the problem is and how much
she/he want to know.
Be aware of what the patient already know.
Share additional information frankly.
Use common language and compassion.
Allow for silence and tears.
Ask the patient to restate what has been said.
Allow time for questions.
 ABCDE technique

4. Deal with reactions.

- Assess and respond to emotional reaction.

- Be aware of body language.

- Be empathetic and supportive.

- Avoid criticizing other health professionals.

 ABCDE technique

5. Encourage and validate

- Explore what the news means to the patient.

- Offer realistic hope, be positive whenever possible (I will do everything I can to

help you. I will do my best to fulfill your wishes..)

- Inquire about patient’s emotional and spiritual needs.

- Offer resources for assistance indicated.

- Give a plan for the patient.

 Resources

1. Hacker & Moore Essentials of Obstetrics and Gynecology

2. Blueprints Obstetrics and Gynecology

3. Alsbeih, Ghazi. “HPV Infection in Cervical and Other Cancers in Saudi Arabia: Implication for
Prevention and Vaccination.” Frontiers in oncology vol. 4 65. 31 Mar. 2014,
doi:10.3389/fonc.2014.00065
THANK YOU
any questions?