Cervical CancerCervical Cancer
CervixCervix Lower part of the Lower part of the
uterusuterus Connects the body of Connects the body of
the uterus to the the uterus to the vagina (birth canal)vagina (birth canal)
Source: American Cancer SocietySource: American Cancer Society
Cervical CancerCervical Cancer
Begins in the lining of the cervixBegins in the lining of the cervix
Cells change from normal to pre-Cells change from normal to pre-cancer (dysplasia) and then to cancer cancer (dysplasia) and then to cancer
Source: American Cancer SocietySource: American Cancer Society
Three TypesThree Types
Squamous cell CarcinomasSquamous cell Carcinomas– Cancer of flat epithelial cellCancer of flat epithelial cell– 80% to 90%80% to 90%
Adenocarcinomas Adenocarcinomas – Cancer arising from glandular epitheliumCancer arising from glandular epithelium– 10% - 20%10% - 20%
Mixed carcinomaMixed carcinoma – Features both typesFeatures both typesSource: American Cancer SocietySource: American Cancer Society
StatisticsStatistics 10,52010,520 new cases in the U.S. this year new cases in the U.S. this year 3,9003,900 will die will die 50%50% are diagnosed between ages 35 and 55. are diagnosed between ages 35 and 55. 20%20% at the age of 65 or over. at the age of 65 or over. Rarely occurs in women younger than 20Rarely occurs in women younger than 20 Noninvasive is four times more commonNoninvasive is four times more common 74%74% decrease in deaths between 1955 and decrease in deaths between 1955 and
1992 in the U.S.1992 in the U.S. Death rate continuous to decline by Death rate continuous to decline by 2%2% a year a year
Source: American Cancer SocietySource: American Cancer Society
Lifetime Probability of Developing Cancer, byLifetime Probability of Developing Cancer, by Site, Women, US, 1998-2000 Site, Women, US, 1998-2000
Site Risk
All sites 1 in 3Breast 1 in 7Lung & bronchus 1 in 17Colon & rectum 1 in 18Uterine corpus 1 in 38Non-Hodgkin lymphoma 1 in 57Ovary 1 in 59Pancreas 1 in 83 Melanoma 1 in 82Urinary bladder 1 in 91Uterine cervix 1 in 128
Source:DevCan: Probability of Developing or Dying of Cancer Software, Version 5.1 Statistical Research and Applications Branch, NCI, 2003. http://srab.cancer.gov/devcan
Signs and SymptomsSigns and Symptoms Vaginal bleedingVaginal bleeding
Menstrual bleeding is longer and heavier than usualMenstrual bleeding is longer and heavier than usual
Bleeding after menopause or increased vaginal Bleeding after menopause or increased vaginal dischargedischarge
Bleeding following intercourse or pelvic examBleeding following intercourse or pelvic exam
Pain during intercoursePain during intercourse
Source: American Cancer SocietySource: American Cancer Society
Risk FactorsRisk Factors Human papillomavirus infection (HPV) – Primary factorHuman papillomavirus infection (HPV) – Primary factor
– HPV 16, HPV 18, HPV 31, HPV 33, HPV 45HPV 16, HPV 18, HPV 31, HPV 33, HPV 45– 50% are caused by HPV 16 AND 1850% are caused by HPV 16 AND 18
Sexual behaviorSexual behavior SmokingSmoking HIV infectionHIV infection Chlamydia infectionChlamydia infection DietDiet Oral contraceptivesOral contraceptives Multiple pregnanciesMultiple pregnancies Low socioeconomic statusLow socioeconomic status Diethylstilbestrol (DES)Diethylstilbestrol (DES) Family historyFamily history
Source: American Cancer SocietySource: American Cancer Society
PreventionPrevention Avoiding the risk factorsAvoiding the risk factors
– Especially HPVEspecially HPV– Help for low-income women (NBCCEDP)Help for low-income women (NBCCEDP)
Having the Pap TestHaving the Pap Test– 3 years after first vaginal intercourse or by age 3 years after first vaginal intercourse or by age
21.21.– Have test annuallyHave test annually
Source: American Cancer SocietySource: American Cancer Society
DiagnosisDiagnosis Cervical Cytology (Pap Test)Cervical Cytology (Pap Test)
– Cells are removed from the cervix and Cells are removed from the cervix and examined under the microscope.examined under the microscope.
– Can detect epithelial cell abnormalitiesCan detect epithelial cell abnormalities Atypical squamous cellsAtypical squamous cells Squamous intraepithelial lesionsSquamous intraepithelial lesions Squamous cell carcinoma (likely to be Squamous cell carcinoma (likely to be
invasive)invasive)
Source: American Cancer SocietySource: American Cancer Society
DiagnosisDiagnosis
Additional testingAdditional testing– ColposcopyColposcopy
Cervix is viewed through a colposcope and Cervix is viewed through a colposcope and the surface of the cervix can be seen close the surface of the cervix can be seen close and clear.and clear.
– Cervical BiopsiesCervical Biopsies Colposcopic biopsyColposcopic biopsy – removal of small section – removal of small section
of the abnormal area of the surface.of the abnormal area of the surface. Endocervical curettageEndocervical curettage – removing some – removing some
tissue lining from the endocervical canal.tissue lining from the endocervical canal. Cone biopsyCone biopsy – cone-shaped piece of tissue is – cone-shaped piece of tissue is
removed from the cervixremoved from the cervix
StagingStaging FIGO System FIGO System (International Federation Of Gynecology and Obstetrics)(International Federation Of Gynecology and Obstetrics)
Has five stages – 0 to 4Has five stages – 0 to 4– Stage 0Stage 0 Carcinoma in situ Carcinoma in situ– Stage 1Stage 1 Invaded cervix, but has not spread. Invaded cervix, but has not spread.– Stage 2Stage 2 Has spread to nearby areas, not leaving pelvic Has spread to nearby areas, not leaving pelvic
area.area.– Stage 3Stage 3 Cancer has spread to the lower part of the Cancer has spread to the lower part of the
vagina.vagina.– Stage 4Stage 4 Cancer has spread to nearby organs; Cancer has spread to nearby organs;
metastasis. metastasis.
Source: American Cancer SocietySource: American Cancer Society
Survival RateSurvival Rate 5-year survival rate is 92% for earliest stage 5-year survival rate is 92% for earliest stage
71% for all stages combined71% for all stages combined
Source: American Cancer SocietySource: American Cancer Society
TreatmentTreatment SurgerySurgery
– Preinvasive cervical cancerPreinvasive cervical cancer CryosurgeryCryosurgery Laser surgeryLaser surgery ConizationConization
– Invasive cervical cancerInvasive cervical cancer Simple hysterectomySimple hysterectomy
– Removal of the body of the uterus and cervix.Removal of the body of the uterus and cervix. Radical hysterectomy and pelvic lymph node dissectionRadical hysterectomy and pelvic lymph node dissection
– Removal of entire uterus, surrounding tissue, upper part of Removal of entire uterus, surrounding tissue, upper part of the vagina, and lymph nodes from the cervix.the vagina, and lymph nodes from the cervix.
RadiationRadiation
ChemotherapyChemotherapy
Source: American Cancer SocietySource: American Cancer Society
What’s new in cervical cancer What’s new in cervical cancer research and treatment?research and treatment?
HPV testHPV test
HPV vaccineHPV vaccine
Radical trachelectomy procedureRadical trachelectomy procedure
Other clinical trialsOther clinical trials
Source: American Cancer SocietySource: American Cancer Society
Tata Memorial Hospital
Evidence Based Guidelines
Evidence Based TMH Guidelines - Feb 2003
STAGE Ib & IIa
Evidence Based TMH Guidelines - Feb 2003
STAGE Ib & IIa
Type III Hysterectomy
+
Pelvic Lymphadenectomy
Type III Hysterectomy
+
Pelvic Lymphadenectomy
IB1: Radical Radiation Therapy
IB2/IIA: Concomitant CT+RT
IB1: Radical Radiation Therapy
IB2/IIA: Concomitant CT+RT
Low riskLow risk Intermediate riskIntermediate risk High riskHigh risk
ObservationObservation Pelvic RadiationPelvic Radiation Concomitant
chemo radiation
Concomitant
chemo radiation