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Module 5: Cervical Cancer

Module 5: Cervical Cancer. Instructor Anne White, MD, MS, FAAFP. Unit 3: Major Cancers, Prevention, & Staging. Objectives. Cervix images Burden of Cervical Cancer Risk factors Screening Recommendations &Techniques Diagnostic techniques Cancer Staging Therapies

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Module 5: Cervical Cancer

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  1. Module 5: Cervical Cancer Instructor Anne White, MD, MS, FAAFP Unit 3: Major Cancers, Prevention, & Staging

  2. Objectives Cervix images Burden of Cervical Cancer Risk factors Screening Recommendations &Techniques Diagnostic techniques Cancer Staging Therapies Bio-Psycho-Social Aspects of Cervical Cancer Unit 3: Major Cancers, Prevention, & Staging

  3. CERVICAL ANATOMY

  4. BEAUTIFUL NORMAL CERVIX

  5. Epidemiology and Burden of Disease 04/01/2011 exp.

  6. In 2005, almost 12,000 women in the U.S. were told that they had cervical cancer. 3,924 women died from the disease.2 U.S. Cancer Statistics Working Group. Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2009. Available at: www.cdc.gov.uscs.

  7. Annual us direct costs Annual US Direct Costs: $4.0 billion (2000 US dollars)1 Cervical Cancer Cervical Abnormalities • Abnormal Pap test • Mild cervical lesionsa • Precancerous lesionsb Other - Genital warts $146 million ~96% of costs $3.6 billion $167 million 1. Chesson H et al. Persp Sex Repro Health. 2004;36:11-19. 2. Clifford G et al. Cancer Epidemiol Biomarkers Prev. 2005;14:1157-64. 3. Smith J et al. Int J Cancer. 2007;121:621-32. 4. Data on File. GlaxoSmithKline. a~10% of mild cervical lesions are caused by HPV 6/112 b~53% of precancerous lesions are caused by HPV-16/183,4 Pap = Papanicolaou

  8. Majority of Direct Costs for HPV Disease Are Due to Cervical Abnormalities

  9. RISK FACTORS FOR CERVICAL CANCER

  10. THE BIGGEST RISK FACTOR HUMAN PAPILLOMA VIRUS = HPV HPV HPV HPV POINT MADE?

  11. Risk factors for cervical cancer MORE Risk Factors for Cervical Cancer • YOUNG AGE of first intercourse – IMMATURE cervix vulnerable to viral damage. • Multiple sexual partners – more opportunity to be exposed to more types of HPV. • Smoking – Nicotine acts like a fertilizer for HPV. Doubles the risk for Cervical Cancer. • Use of OC’s – theory is that there is a correlate with higher #’s of sexual partners

  12. MORE RISK FACTORS … Partner with known HPV infection Suppressed immune system i.e. HIV Infrequent pap smears – HUGE risk factor

  13. High Impact of Cervical Cancer & Precancerous Lesions in the United States

  14. In the United States, cervical cancer is the second leading cause of cancer-related death in women between the ages of 20 and 391 Every minute a woman is diagnosed with a precancerous lesion2,a,b aPrecancerous lesion = Cervical intraepithelial neoplasia (CIN) grades 2/3 Every hour a woman is diagnosed with cervical cancer3,b Every 2 hours a woman dies of cervical cancer3,b bEstimated 1. Jemal A et al. CA Cancer J Clin. 2009;59:225-49. 2. Saslow D et al. CA Cancer J Clin. 2007;57:7-28. 3. ACS. Facts & Figures. 2009. 04/01/2011 exp.

  15. Most HPV-associated Cancers Occur in the Cervix1 Cervical Cancer 87.8% 12.2% Other HPV-associated cancers 1. Parkin D et al. Int J Cancer. 2006;118:3030-44. 04/01/2011 exp.

  16. Infection With Oncogenic HPV Is Necessary to Cause Cervical Cancer1 1. Walboomers J et al. J Pathol. 1999;189:12-19.

  17. Natural History of HPV Infection Non-oncogenic Infections Oncogenic Infections Commonly caused by HPV types 16 & 18 Persistent Infection Persistent Infection Mild Cervical Lesions Non-oncogenic infections do not lead to precancerous lesions or cervical cancer2 Precancerous Lesions Cervical Cancer Mild Cervical Lesions/ Genital Warts Most HPV infections will clear, and most cervical lesions will not progress3-5 1. Walboomers J et al. J Pathol. 1999;189:12-19. 2. Trottier H, Franco E. Vaccine. 2006;24S1:S4-15. 3. Moscicki A et al. Vaccine. 2006;24S3:42-51. 4. Einstein M. Cancer Immunol Immunother.2008;57:443-51. 5. Östör A. Int J Gynecol Pathol. 1993;12:186-92.

  18. Globally – Distribution of Oncogenic HPV Types in Precancerous Lesions and Cervical Cancer1 30% 48% Oncogenic HPV Type Prevalence (%) 70% 52% 1. Smith J et al. Int J of Cancer. 2007;121:621-32.

  19. REGRESSION/PROGRESSION Most HPV infections will clear and most cervical lesions will not progress1-3 1. Moscicki A et al. Vaccine. 2006;24S3:42-51. 2. Einstein M. Cancer Immunol Immunother.2008;57:443-51. 3. Östör A. Int J Gynecol Pathol. 1993;12:186-92.

  20. White epithelium

  21. Cervical Lesions Are Most Common Among Women in Their Twenties CIN 2/3 Data from Kaiser Permanente Population in Oregon1,a aPrior to introduction of existing vaccine CIN 1 Incidence per 100,000 Women Age, years 1. Insinga R et al. Am J Obstet Gynecol. 2004;191:105-13. 04/01/2011 exp.

  22. GeorgiaMortalitySTATS

  23. Oklahoma Mortality STATS

  24. Majority of Costs for CIN 2/3 Occur Among Women in Their Twenties CIN 2/3 CIN data from Kaiser Permanente Population in Oregon1,a Annual Costs per 100,000 Women (2002 US dollars) Cervical cancer CIN 1 Age, years aPrior to introduction of existing vaccine 1. Insinga R et al. Am J Obstet Gynecol. 2004;191:114-20.

  25. The Immune System and HPV 04/01/2011 exp.

  26. HUMAN PAPILLOMA VIRUS DNA virus - 100 types 30-40 can infect anogenital tissue Types 16 & 18 have the highest cancer potential. Types 6 & 11 cause most genital warts but rarely cancer.

  27. Summary Infection with oncogenic HPV is necessary to cause precancerous lesions and cervical cancer • Oncogenic HPV types 16 and 18 cause the majority of cervical cancers Cervical cancer accounts for the majority of cancers caused by oncogenic HPV After natural infection, antibody levels may not be sufficient to prevent reinfection HPV and cervical cancer place a considerable burden on health care in the United States

  28. PREVENTION OF HPV INFECTION CONDOMS & more CONDOMS Reduce risk by 50-70% depending on consistency of use

  29. MORE PREVENTION MINIMIZE NUMBER OF PARTNERS

  30. VACCINES GARDASIL Introduced 2006 CERVARIX Introduced 2009

  31. GARDASIL Age 11 -26 Girls and Women Includes four most common viral types: 6 & 11 – genital warts 16 & 18 – oncogenic types implicated in cervical cancer Approved for boys October 2009 to prevent genital warts. Theoretical ability to reduce transference of all four viral types to women.

  32. GARDASIL ENDORSED BY THE FOLLOWING for Girls/Women: CDC ACIP – Advisory Committee on Immunization Practices AAFP American Academy of Family Practice AAP American Academy of Pediatrics SAM Society for Adolescent Medicine AMCA American College Health Association

  33. CERVARIX CERVARIX is indicated for protection against cervical disease caused by oncogenic HPV types 16 and 18 Overall impact on HPV disease is a combination of efficacy against vaccine and non-vaccine oncogenic HPV types CERVARIX significantly reduced the incidence of precancerous lesions in 2 analyses of 12 oncogenic non-vaccine HPV types Significant efficacy was observed only against HPV type 31

  34. You may see this again…..Hint hint ….. Types 16 & 18 have the highest cancer potential. • Types 6 & 11 cause most genital warts but rarely cancer.

  35. PAP SMEARRECOMMENDATIONS USPSTF US Preventive Services Task Force ACOG American College of Ob-GYN

  36. PAP SMEAR SCREENING USPSTF VERY conservative Start age 21 or within 3 years of “coital debut” . Stop age 65 with history normal Paps. Don’t screen if S/P hyst AND history normal Paps Cannot recommend for or against liquid vs conventional Pap Cannot recommend for or against HPV testing We LOVE getting our Paps!

  37. ACOG RECOMMENDATIONS Issued November 2009 Initiate screening age 21 Q 2 years ages 21 – 30 Q 3 years over age 30 if hx 3 consecutive neg Hysterectomy with history of normal Pap smears - NO PAPs Ok to stop PAPs age 65 - 70

  38. CERVICAL CELLS Top frame normal cells. Small nuclei are obvious. Bottom frame – Dysplastic cells: note the large, ugly nuclei in the three center cells.

  39. PRE AND POST PAP 1941 introduction of PAP smear. 1941 260,000 deaths from cervical cancer. 2007 3,700 USA predicted deaths from cervical cancer

  40. CANCER OR NOT? Benign cervical polyp Easily removed without pain

  41. CERVICAL CANCER

  42. Normal or Abnormal? Who knows? A totally normal appearing cervix can harbor precancerous cells due to HPV infection.

  43. SURVIVALRATES Survival rate indicates the percentage of people with a certain type and stage of cancer who survive for a specific period of time after their diagnosis.

  44. SURVIVAL RATES Five-year survival rates are used as a standard way of discussing prognosis as well as a way to compare the value of one treatment with another. It does not mean that a patient can expect to live for only 5 years after treatment or that there are nocuresfor cancer.

  45. SURVIVAL RATES 100 women with cervical cancer 95 will be alive after 5 years 5 will die prior to 5 years some will die of other causes i.e. heart, etc.

  46. DIAGNOSIS COLPOSCOPY • Observe the cervix under magnification • Look for characteristic changes of dysplasia/HPV • Obtain biopsies • Correlate findings with pathology report • Procedure is uncomfortable.

  47. Colposcopic Image

  48. NOW WHAT? RADIATION IMPLANTS RADICAL HYSTERECTOMY Conization LEEP HYSTERECTOMY Chemotherapy

  49. LEEP Loop Electro Excision Procedure CIS & early Stage I

  50. Cold knife cone biopsy • May also be performed with a Laser • CIS & early Stage I

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