DR GEETANJALI S VERMACSI RAINY MULTISPECIALITY HOSPITAL
“For most of history, Anonymous was a woman.” Virginia Wool
HISTORY OF WOMEN’S DAY• This was first celebrated on 19th March 1911 but is now celebrated every 8th March.• Women join to celebrate the date that represents equality, justice,peace and development.• International Women’s Day is rooted in the struggle of women seeking to participate on an equal footing with men.
Mary Wollstonecraft• She was the first woman to demand votes for women.• 1792 her book entitled Vindication of the Rights of Women argued for equal education, and for single women to earn their own living.• She fought hard for women even though she had much personal unhappiness. Unfortunately this led her to being criticised and her ideas dismissed by many, including women.
• Although rich women had an easier life they had a common denominator with poor women: they had no legal status. A married woman’s earnings belonged to her husband. Her property and goods all belonged to her husband.• A woman could not vote.• A woman could no go to university.• She could not get a divorce on grounds of adultery (although her husband could).• It was almost impossible to get a divorce at all until 1857.• The law said that children had one parent, a father. He decided on their education and if a couple separated he could refuse to let the mother even see them.
Caroline NortonCaroline had a brutal husband whoaccused her of adultery. She wasunable to defend herself in court asshe had no legal status. Herhusband took her children and alsoall her earnings (she was a writer).Caroline wrote on the Custody ofInfants and had some effect: 1839the bill said children under sevencould stay with their mother if thecourts agreed she had a goodcharacter. Caroline also wrote onmaking divorce laws fairer.Therefore she helped legal equalityfor women.
Barbara Bodichon Barbara supported the Married Women’s Property Bill in 1856. This resulted in an Acts of Parliament allowing women living with husbands or those separated to keep their own earnings By 1882 women could own their own property and give it to whoever she wished.
Voting: arguments used against women• Women are incapable of rational thought.• Women are physically too frail and weak to take on the burden of decision.• Women are incapacitated by frequent childbearing to bother to vote.• Men will make the right decisions for them.• If women have the vote they will upset the current order and cause unpleasant changes.
“In politics, If you want anything said, ask a man. If you want anything done, ask a woman.” Margaret Thatcher
“You educate a man; you educate a man. You educate a woman; you educate a generation.” Brigham Young
Florence Nightingale • Worked as a nurse in the Crimean and drastically reduced the death rate. • Introduced nursing as a profession and started a nursing school. • Involved in improving military hospitals • Used health statistics effectively • Hospital planning • Community nursing.
Mary Seacole • A nurse who used herbs and natural remedies. • Self funded to go to the Crimean and nurse soldiers on the battlefield - a true ‘field’ nurse attending the wounded on the front line • Sometimes called the ‘forgotten Nightingale’.
Mother TheresaA Catholic nun whodevoted her life tocaring for the poorand sick in Calcutta,India. She was reveredas a living saint for herwork and won theNobel Peace Prize.
Marie Curie• She won two Nobel prizes for her work in science.• Discovered radium with her husband Pierre• In WWI she equipped ambulances with mobile X ray units and drove them to the front lines• Her work helped X rays in surgery• Her research led to treatment of cancer by radiation.
EPIDEMIOLOGYIncidence:• Breast cancer is the most common lethal neoplasm in women.• The incidence varies among different populations – 1 out of 8 women will have BC in her life--time. – ~ 25 percent of women with cancer have BC.• The incidence of male breast canceris about 1% of all breast cancer cases occur in men.
US incidence – Affects 1 in 8 women living to 85yrs age – Total cases 2008 : 211,000 – Total deaths : 40,500 (1/6th of female deaths) Ethnic incidence Causacians – hispanic - asians – african american Stage at presentation localised 58% (node -) Regional 32% (node + / stage 3)
Age Incidence by age 30 1 in 2,525 by age 40 1 in 217 by age 50 1 in 50 by age 60 1 in 24 by age 70 1 in 14 by age 80 1 in 10
RISK FACTORS• Highly elevated RF (relative at 4 times risk) – Female – Age>50yrs – Personal history of prior breast cancer – Family history – Atypical proliferative benign breast disease esp with family history• Moderately elevated RF (relative at 2 - 4 times risk) – Any 1st degree relative with breast cancer – Upper SES – Prolonged interrupted menses – Post menopausal obesity – h/o cancer ovary or endometrium – proliferative benign breast with no atypia• Slightly elevated RF (relative at 1-2 times risk) – Moderate alcohol intake – Menarche <12yrs old – HRT/ OCP/ Diet
PATHOLOGY Non – Invasive Lobular (LCIS) Ductal (DCIS) InvasiveLow Risk* Standard (high) Risk Pure Tubular Ductal Pure Mucinous/Colloid Lobular Pure Papillary Medullary ** Pure Medullary ? Mixed Squamous* Requires careful pathology review** atypical and mixed
CLINICAL PRESENTATIONThe majority of carcinoma in situ, T1, or T2:• Painless or slightly tender breast mass or have an abnormal screening mammogram.• Patients with more advanced tumors: breast tenderness, skin changes, bloody nipple discharge, or occasionally change in the shape and size of the breast.• Rarely patients may present with axillary lymphadenopathy (which occasionally may be painful) or distant metastasis.
SCREENINGMAMMOGRAPHYEstablished Guidelines Annual 2 view study in women 50 years of age and older • Meta - analysis – 13 randomized trials – 26% reduction in breast cancer
• Screening – Patient without physical finding or symptoms • MLO - mediolateral oblique (side) • CC - craniocaudal (above)• Diagnostic – new symptoms - lump, thickening, skin change – additional imaging including magnification – additional evaluation including US
• INTERPRETATIONBIRADS - Breast Imaging Reporting and Data SystemCategory Assessment Recommendations 0 Incomplete Additional views 1 Negative Routine - 12 months 2 Benign Routine - 12 months 3 Probable Benign F/U short term -6mos. 4 Suspicious Biopsy considered 5 Cancer suggestedAppropriate action
DIAGNOSIS• Fine Needle Aspiration• Ultrasound Guided Core Biopsy• Excisional or Incisional Biopsy
TREATMENT• NON INVASIVE DUCTAL 1) Complete Excision Alone Possible for low risk lesion, but “low risk” difficult to define 2) Complete Excision + RT Relative Contraindications 1 – in 2 or more Margins need to be quadrants negative, 2 – diffuse or malignant >1mm, less than 10 appearing Ca++ mm. 2-3 mm usually Post excision Imaging 3 – persistent + margins recommended - specimen mammogram 4 – not RT candidates3) Mastectomy and/or prior RT - post lump mammogram pregnancy CTD – lupus/scleroderma
Management Options – Radiation Therapy• Excision Alone – recommended• Post Mastectomy – unnecessary• No effect on mortality• Decreases Breast Recurrence Risk by 50% (1% ½%/yr) Treatment is to Breast Only Contraindications: Relative Contraindications 1 – in 2 or more quadrants Omitted in low risk? 2 – diffuse or malignant appearing Ca++ controversial 3 – persistent + margins 4 – not RT candidates < 5mm, low grade, unicentric prior RTpregnancy CTD – lupus/scleroderma
NON INVASIVE LOBULARFeatures Increased risk of subsequent invasive cancer (~ 1%/yr) Likely to be bilateralManagement Options Observation ( negative surgical margins NOT required) No SLNBx or ALND is necessary Bilateral mastectomies can be considered Potential candidates for Tamoxifen or chemoprevention trialsWork-Up/Follow-Up Bilateral mammogram, then yearly Exam every 6-12 months
INVASIVE Stages I – IIB + IIIA (T3 > 5 cm, N1 only)Management Priorities Surgery Adjuvant Chemotherapy Hormonal Rx* Radiation Rx*
Introduction• Cervical cancer is the second most common cancer among women and is the primary cause of cancer- related deaths in developing countries• Cervical cancer, in women, is the second most common cancer worldwide, next only to breast cancer. In India, cervical cancer is the most common woman-related cancer, followed by breast cancer
• Cancer of the cervix is the most common female genital cancer in developing countries. Every year about 500,000 women , acquire the disease and 75% are from developing countries.• The cervical cancer burden in India alone is estimated to be 100,000 .
•The number of deaths due to cervical cancer isestimated to rise to 79,000 by the year 2010.•The cancer mostly affects middle- aged women(between 40 and 55 years), especially those from thelower economic status who fail to carry out regularhealth check-ups due to financial inadequacy.In urban areas, cancer of the cervix account for over40% of cancers while in rural areas it accounts for65% of cancers as per the information from thecancer registry
Risk factors and aetiology HPV (Human papilloma virus ) infection mainly 16,18 the main aetiological is infection with subtypes of HPV (16,18) Coitus at young age: <16 years old increased risk by 50% Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds. Smoking Smoking for> 12 years increase the risk by 12.7 folds
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids. Barrier method decrease the risk Immuno suppresive pt Low socioecomic class
Type of patient:• Multiparous.• Low socioeconomic class.• Poor hygiene.• Prostitute.
Predisposing factors:• Cervical dysplasia.• Cervical intraepithelial neoplasia• CIN III / CARCINOMA IN SITU• THE LESION PROCEEDS THE INVASION BY 10- 12 YEARS The cervical cancer burden in
Symptoms: Early symptoms Late symptoms- None. - Pain, leg oedema.- Thin, watery, blood tinged - Urinary and rectal vaginal discharge frequently symptoms goes unrecognized by the dysuria patient. haematuria- Abnormal vaginal bleeding rectal bleedingIntermenstrual constipationPostcoital haemorrhoidsPerimenopausal - UraemiaPostmenopausal- Blood stained foul vaginal discharge.
Cervical cancer prevention• Pap smears performed once per year until age 30• >30 yrs - once every 3 yrs if pap and HPV negative• 75% reduction in cervical cancer in countries with adequate screening
STAGES OF CANCER CERVIX• Once cancer cervix is found (diagnosed), more tests will be done to find out if the cancer cells have spread to other parts of the body. This testing is called staging.• TO PLAN TREATMENT, A DOCTOR NEEDS TO KNOW THE STAGE OF THE DISEASE.
TREATMENT• Surgical.• Radiotherapy.• Radiotherapy & Surgery.• Radiotherapy and Chemotherapy followed by Surgery.• Palliative treatment.
Surgical procedure• The classic surgical procedure is the wertheim’s hystrectomy for stage Ib,IIa, and some cases of IIb in young and fat patient
PROGNOSISDepends on:• Age of the patient.• Fitness of the patient.• Stage of the disease.• Type of the tumour.• Adequacy of treatment.
THE OVERALL 5 YEARS SURVIVAL FOLLOWING THERAPY:• Stage I -------80%• Stage II-------50-60%• Stage III-------30-40%• Stage IV-------4%
Human Papillomavirus Vaccines• HPV4 (Gardasil) – contains types 16 and 18 (high risk) and types 6 and 11 (low risk)• HPV2 (Cervarix) – contains types 16 and 18 (high risk)• Both vaccines are supplied as a liquid in a single dose vial or syringe• Neither vaccine contains an antibiotic or a preservative
Human Papillomavirus Vaccines• HPV4 vaccine is approved for – females 9 through 26 years of age for the prevention of cervical cancers, precancers and genital warts – males 9 through 26 years of age for the prevention of genital warts• HPV2 vaccine is approved for – females 10 through 25 years of age for the prevention of cervical cancers and precancers – not approved for males or for the prevention of genital warts
HPV Vaccine Schedule and Intervals• HPV4- 0, 2, 6 months• HPV2- 0, 1, 6 months• ACIP recommends- 0, 1 to 2, 6 months• ACIP has not defined a maximum interval between HPV vaccine doses• If the interval between doses is longer than recommended continue the series where it was interrupted
Conclusions• Cervical cancer affects women in our community• Cervical cancer is a serious disease – Risks just from preventing cancer – 30% mortality from cervical cancer – Long term effects after treatment for cervical cancer• Cervical cancer is preventable – Regular pap smears – HPV vaccination