1. Cervical Lesions Maria Julieta V. Germar, FPOGS, FSGOP Section of Gynecologic Oncology UP College of Medicine-Philippine General Hospital The Medical City Ateneo School of Medicine and Public Health 16 November 2011

2. How do we diagnose cervical cancer ? Normal Cervix Cervical Cancer

3. Squamous Cell Carcinoma HPV 16, 18

4. Cervical AdenocarcinomaHPV 16,18, 45

5. How is it staged ? IIIB

6. CLINICAL STAGING • Bimanual examination of the pelvis, which includes palpation of the uterus and ovaries. • Rectovaginal Exam- to assess the parametria

7. Rectovaginal Exam- to assess the parametria parametria

8. October 2009 Update:New Cervical Cancer Staging

9. STAGING Revised October 2009

10. STAGING Revised October 2009

11. STAGING Revised October 2009

12. 1995 FIGO STAGING FOR CERVICAL CANCER STAGE IIA The carcinoma extends beyond the uterus but has not extended to the pelvic wall or to the lower third of the vagina with NO parametrial involvement

13. 1995 FIGO STAGING FOR CERVICAL CANCER STAGE IIB The carcinoma extends beyond the uterus but has not extended to the pelvic wall or to the lower third of the vagina With obvious parametrial involvement

14. STAGING Revised October 2009

15. 1995 FIGO STAGING FOR CERVICAL CANCER Stage III The cancer extends to the pelvic wall.The tumor involves the lower third of the vagina. All cases of hydronephrosis or non-functioning kidneys are included. IIIAWithout extension to the pelvic wall IIIB With extension to the pelvic wall and/or hydronephrosis or non-functioning kidney.

16. STAGING Revised October 2009

17. 1995 FIGO STAGING FOR CERVICAL CANCER IVB Spread to distant organs Stage IV The cancer extends beyond the true pelvis or involves the mucosa of the bladder or the rectum. IVA Spread to adjacent organs

18. IV V I 2% 5% 14% II III 38% 41% n = 532 Cervical cancer Majority of Filipina women we see ( 40-60 %) are in stage III disease Section of Gynecologic Oncology Annual Report 2008. UP-PGH Department of Obstetrics and Gynecology Staff Conference. 2009 (unpublished)

19. IIIB CHEMOTHERAPY AND RADIOTHERAPY SURGERY

20. Early Stage (Stage I-IIA)-SURGERYRADICAL HYSTERECTOMY

21. Late stage II-IV3-4 months tx RADIATION THERAPY Linear accelerator 25-28 days Brachytherapy 4 sessions CHEMOTHERAPY every week for 6 cycles

22. Cervical cancer Lost to follow-up n = 270 Section of Gynecologic Oncology Annual Report 2008. UP-PGH Department of Obstetrics and Gynecology Staff Conference. 2009 (unpublished)

23. Why ?

24. Cancer of the CervixSUMMARYTotal Cost of Primary Treatment Minimum Wage : Php 404.00/day (USD 9.31)= USD 214 per month Germar, JV, Manalo, A. The Cost of Being Sick with Gynecologic Cancer in the Philippines. SGOP Annual Convention 2007. (unpublished) REVISED 2011

25. CERVICAL CANCER IS PREVENTABLE

26. Prevention of Cervical Cancer: Primary Prevention: • Monogamous sexual relationship between husband and wife • Delay in onset of sexual intercourse • Use of barrier contraceptives • Prompt and adequate treatment of STDs • Prompt and adequate treatment of Pre-invasive disease (CIN) • HPV vaccination

27. Prevention of Cervical Cancer Secondary Prevention:Cytologic Screening/Pap smear

28. The Pap Smear • Begin at age 21 or at the onset of sexual activity, if earlier, and continue every year The risk of developing Cervical Cancer is 5 times higher in women who are not regularly screened.1 National Cancer Institute. Screening for cervical cancer. 2008.

29. The Pap Smear New 2010 recommendations • Begin at age 21 and continue every two years The risk of developing Cervical Cancer is 5 times higher in women who are not regularly screened.1 National Cancer Institute. Screening for cervical cancer. 2008.

30. The risk of developing Cervical Cancer is 5 times higher in women who are not regularly screened.1