Management of Cervical Cancers

1. Management of Cervical Cancers Dr. H. Osore Shesor Clinic Gaborone

2. Cervical Cancer Causative Agents (old teaching) • Smoking, hormones,infections • Cervical cancer is rare in virgins but more common in sexually active women • Cervical cancer more common in women who become sexually active at early age • Highly sexually active women with multiple sexual partners or those in contact with partner who has multiple sexual partners

3. Cancer Cervix • Cancer Cervix is an infectious disease • Therefore Preventable disease

5. Cancer Cervix Magnitude of Problem • 500,000 new cases diagnosed yearly • 80% of new cases occur in developing countries • More than 200,000 deaths each year • Second most cancer amongst women world wide • Botswana- Cancer cervix second commonest nationally

6. Magnitude of the Problem Cont’d • Therefore high risk increase in developing intraepithelial neoplasia and more likely rapid progression to invasive cervical cancer • HIV increases the risk of pre-invasive disease (2 to 12 times higher cytological abnormalities rate in HIV positive women)

7. Cervical Cancer Magnitude of problem cont’d • Women with HIV have a higher prevalence of HPV infection and are more likely to develop persitent infection • Treatment outcomes for patients with cervical cancer are poorer for positive HIV than for HIV negative women

8. Cervical Cancer Types of Cervical Cancers (histopathologically) • Epithelial tumours-(Squamous Cancer) -80-90% • Mesenchymal tissue tumours-( Adenocarcinoma, sarcoma, embryonal)-10-20%

9. Cancer Cervix Symptoms: - • Asymptomatic in early stages/preclinical stage • Haemorrhage-Metrorrhagia /Postcoital • Bleeding is usually severe in cauliflower-like exophytic (growth) lesions • Discharge- watery, offensive, blood stained

10. Clinical features- Cachexia( wasting) and pain in advanced lesions Signs:- -Obvious lesion or growth may or may not be present -when obvious lesion growth present, it may be exophytic cauliflower-like or endophytic, ulcerative and scirrhous - Cancer Cervix

11. Cancer Cervix Signs:- • Cervix usually indurated, hard, friable, easily bleeds on contact and its mobility may be restricted or lost • Endocervical growth- cervix is expanded, firm and feels barrel shaped

12. Cervical Cancer Diagnosis • Pap Smear examination • Colposcopy • Biopsy:- -Excisional biopsy preferred to Punch biopsy Schiller’s Test/Acetic Acid helps in selecting the biopsy site where growth may not be obvious Cone biopsy-in early cases • Endocervical curettage

13. Cancer Cervix Investigations • Complete Physical Exam, Pelvic Exam, Rectal Exam- EUA to be done • Abdominal/Pelvic Ultrasound • Chest X-ray • IVP • Cystoscopy • Proctosigmoidoscopy

14. Cancer Cervix Treatment Quandary Surgery Or Radiotherapy?

15. Cervical Cancer Staging-(Clinical for treatment Planning) (FIGO) • O: Carcinoma-in-situ • 1a: Micro-invasive <=3mmD,<=7mmW (Ia1,Ia2) • 1b: Invasive (>5mm FIGO, >3mm SGO) • IIa: Upper 2/3 of vagina • IIb: Parametrial Involvement ( but Pelvic wall) • IIIa: Lower 1/3 vagina • IIIb: Pelvic wall involvement or hydronephrosis/non-funtional kidney • IVa: Bladder or rectal mucosa involvement • IVb: Distant metastases

17. Cervical Cervix Treatment Options • Stage 1a-1 (<1mm) -Conisation -Simple hysterectomy-abdominal/vaginal approach • Stage 1a-2 (1-3mm, lymph node -1%) -Modified radical hysterectomy-removal of medial ½ of uterosacral and cardinal ligaments with smaller vagina margin

18. Cervical Cancer Treatment –Options: • Recurrent disease:- as per previous treatment -DXT > Exenteration -Surgery- DXT • Stage III and IV-Radiation/!!Exenteration • Radiation, as primary treatment is an option in all stages • Chemotherapy- as adjunct to DXT or for palliation

19. Cancer Cervix Options: • Stage Ib & IIa -Type III hysterectomy (radical hysterectomy with removal of most uterosacral and cardinal ligament, upper 1/3 of vagina, pelvic lymphadenectomy -Postop DXT • Bulky lesions and stage IIb -Full irradiation followed 3-4 weeks later by type II hysterectomy

20. Cancer Cervix Radical hysterectomy • Removes corpus, Cervix, parametria, upper 1/3 of vagina • Uterine arteries divided at origin • Ureters dissected through tunnel • Uterosacral ligament divided near rectum • Lymphadenectomy • Oophorectomy not mandatory

21. Acute:- Fever Perforation Diarrhoea Bladder spasms Chronic:- Proctitis Radiation Cystitis Fistula Enteritis Femoral head necrosis Rectal stricture Cervical CancerTreatment Complications

22. Cancer Cervix Follow-up At 2-3 months interval for 2 years At 3-4 months interval – next 2-4 years At 6 months interval- Rest of the life Tumour markers- CEA

23. Cervical Cancer Five-Year Survival: - Grigsby, P.W., et.al Radiother Oncol 12:289, 1988

24. Cervical Cancer Special Cases –Difficulty to deal with • Invasive cancer on cone biopsy • Cervical stump carcinoma • Invasive carcinoma found after simple hysterectomy • Cervical carcinoma in pregnancy • Large barrel shaped lesion

25. Cancer Cervix Adenocarcinorma • Has poorer prognosis stage by stage relative to squamous cancer • Tends to grow endophytically thus more often undetected until large tumour volume is present

26. Cancer Cervix Summary • Prevention is the best cure • Must carry out evaluation and Proper staging prior to treatment • Surgery and radiotherapy are complimentary-(Surgeon and Radiotherapist together) • Mortality still high stage for stage • Overall mortality is decreasing as cancers are diagnosed early

27. Cervical Cancer Vaccines & Cervical Cancer • Gardasil –manufactured by Merck & Co. in USA • the first vaccine developed to prevent genital lesions and genital warts due to human papillomavirus (HPV) types 6, 11 (warts), 16 and 18 (cervical cancer). • Vaccine is approved for use in females 9-26 years of age • HPV types 16 and 18, cause approximately 70 percent of cervical cancers and against HPV types 6 and 11, cause approximately 90 percent of genital warts. 

28. Cervical Cancer HPV Vaccine cont’d.. • Gardasil is a recombinant vaccine (contains no live virus) • Given as three injections over a (6/12)six-month period • Females are not protected if they have been infected with that HPV type(s) prior to vaccination • Immunization before potential exposure to the virus

29. Cervical Cancer • Gardasil does not protect against less common HPV types not included in the vaccine, therefore routine and regular Pap screening remain critically important to detect precancerous changes in the cervix to allow treatment before cervical cancer develops.

30. Cervical Cancer • Cervarix- second vaccine being researched • Studies suggest that the vaccine may prevent infection against HPV-31 and HPV-45 in addition to HPV strains 16 and 18. • Vaccine has not yet been approved for use in the general population in the United States.

31. Thank You Shesor Clinic Caring for women