The Cervical Cancer is the second most common cancers and it can be easily prevented by timely screening & proper education, awareness program for women.

1. GLOBAL BURDEN OF CA
CERVIX
Dr. Jyoti Malik
▪ Medical Superintendent - JJ Institute of Medical Sciences, Bahadurgarh.
▪ Director, Roots IVF & Fertility Institute, JJIMS.
▪ Secretary General - Haryana Chapter of Indian Society of Assisted Reproduction
(ISAR)

2. What is a Cervix?

3. What is cancer?
Normal:
● Normal cells multiply all the time
● Old cells die and fall off
● New, completely formed, mature cells replace them
● They take over the regular function
Cancer…..normal gone berserk:
● Normal mechanism can be disturbed by many factors (ex:
virus, chemicals in Tobacco, repeated damage)
● Cancer cells are abnormal cells which multiply too fast
● Old cells refuse to die
● New cells don’t mature but keep growing – become a bulk
called “tumour”
● Cannot function normally and start competing with the
normal cells
● Can spread and grow anywhere else in the body and choke
off the normal cells (ex: brain, lungs, liver)

4. CERVICAL CANCER
➢ 4th most common cancer globally.
➢Incidence and mortality of cervical cancer.
➢In India – 2nd most common cancer among women
➢23% of global burden
➢Pap smear coverage : Rural, Urban.

6. What is Cervical Cancer?
● Cancer that affects the “mouth” of the uterus

7. What the doctors see at each stage An actual photograph
What does Cervical Cancer look like?

8. What causes Cervical Cancer?
● A virus
HPV
(Human Papilloma Virus)

9. Why is Cervical Cancer important to you?
> 200 women die every day in India
1 woman every 7 minutes
8 women die every hourCervical Cancer is the
commonest cancer in
Indian Women

10. Why is Cervical Cancer important to you?
New cervical cancer cases
diagnosed annually
India : 1,32,082
World : 4,93,243
Deaths due to cervical
cancer annually
India : 74,118
World : 2,73,505
Rest of World - 73%
India - 27%
1. X. Castellsagué, S. de Sanjose, T. Aguado, K. S. Louie, L. Bruni, J.Muñoz, M. Diaz, K. Irwin, M. Gacic, O. Beauvais, G. Albero, E. Ferrer, S. Byrne, F. X. Bosch. HPV and Cervical
Cancer in the World. 2007 Report. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Available at: www.who.int/hpvcentre
India makes up only 16% of the world’s population
But has 27% of the world’s total cervical cancer cases and deaths every year

11. 1. X. Castellsagué, S. de Sanjose, T. Aguado, K. S. Louie, L. Bruni, J.Muñoz, M. Diaz, K. Irwin, M. Gacic, O. Beauvais, G. Albero, E. Ferrer, S. Byrne, F. X. Bosch. HPV and Cervical
Cancer in the World. 2007 Report. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Available at: www.who.int/hpvcentre
Far more common than other cancers in
Indian women

12. What are the Symptoms of Cervical
Cancer?
● Usually no symptoms in early
stage
● When advanced, there can be the
following symptoms:
● A little bleeding between periods
● Bleeding after sexual intercourse
● Abnormal vaginal discharge
● Sometimes – pain
● During intercourse
● Continuous
● Low back-ache
● Unexplained loss of weight
● Pail face and nails (anemia)

13. How is Cervical Cancer Treated?
● Treatment options depend on the following:
● The stage of the cancer.
● The size of the tumor.
● Your age.
● Your desire to have children.

14. Early Stage Cervical Cancer
● Conservative treatment
(save the uterus and part of the
cervix)
● Burn the abnormal part of cervix
with electric current
(electro-cautery)
● Destroy the abnormal area by
freezing it
(cold co-agulation)
•Excellent chance of saving life
•Can have babies
(may have some difficulty)

15. Later Stage of Cervical Cancer
● Surgery
1. Medium spread of cancer
– remove uterus with
cervix, tubes and ovary
● Good chance of survival
● Can’t have babies
2. Late Stage
● Extensive surgery removing
other parts of the body as
well
● Needs radiation therapy and
chemotherapy
● Chances of survival vary

16. What is PAP SMEAR TEST
● Is obtaining sample of exfoliated cell (dead cells that are
shed) @ simple test to look at cervical cells
● The specomen should be obtained 2 weeks after the first
day of LMP taken by brushing or scraping.

17. WHEN TO DO PAP SMEAR
● All women have initial pap smear test no later than 21 years
old
● 3 years after onset of sexual intercourse
● After initial test, have annually or biannually
● After age 30, because screened for 2-3 years unless has high
factor developing cervical cancer.

19. Progression from Infection to Cervical Cancer
7-30 years
Infection
CIN 1
CIN 2/3 Invasive CxCa
Ca. 50%
8-18 months
infection
Virus production
transformation CxCa
invasion
DNA Detection
E6/E7 RNA/Protein detection!
CytologyScreening Methods:

20. Primary Screening: HPV Detection vs Cytology
Cuzick et al., Int J Cancer 2008
HPV Test: high Sensitivity
But Cytology: low Sensitivity / high Specificity
1) Internationally shift from
cytology to HPV Test
2) WHO: „countries that do not
yet have cytology established
should start directly with HPV
Testing“
3) Maybe use cytology
as triage method
4) Potentially better molecular
triage tests possible

21. Indication of Colposcopy
➢ Epithelial cell abnormalities
detected by cervical cytology
➢ Positive high risk HPV DNA in ASC-
US triage
➢ Suspicious cervical lesions
➢ Vulvur or vaginal neoplasia
➢ History of in-utero DES exposure
➢ Sexual partner of patients with
genital tract neoplasia
➢ Oncogenic Human Papillomavirus
in appropriate guideline algotithms
➢ Unexplained vaginal bleeding
➢ Post-Coital bleeding
➢ Positive screening test by
Cervicography or Speculoscopy

22. Basic Satisfactory Requirements of
Colposcopic Exam
➢Adequate Visualization
➢Entire TZ Zone seen
➢Abnormal areas seen in entirety
➢Endocervical Canal free of Dysplasia
➢No Evidence of Invasive Cancer
➢Abnormal Areas Biopsied
➢ECC Completed (Non-Pregnant patients)

23. Colposcopy-Objectives
● Determines the presence of invasive cancer
● Localizes the squamocolumnar junction
● Identifies the most severe disease for biopsy
● Evaluates the extent of disease

24. Instrumentation Procedure
● Colposcope
● Vaginal speculum
● Endocervical speculum
● Large & Small swabs
● Endocervical curette
● Cervical biopsy forceps
● Solutions
● Normal saline
● Acetic Acid
● Monsel’s

26. ● A method of identifying
● outer & inner borders of the transformation zone

27. Colposcopic Examination
● Obtain Pap, cultures, KOH as needed
● Perform Cervical Colposcopic Exam
● Use Green Filter, if needed
● Mentally Map Cervical Landmarks and abnormal areas
● Colposcopic magnification of 10x – 15x
● Is Exam satisfactory?

28. What you should know about
vaccination
● Vaccination is the only true form of
“prevention” – stops the disease from
happening in the first place
● There are two vaccines available
today:
● Quadrivalent (“four type”) - Gardasil
● Protects from 6,11,16,18
● Partial protection from 33, 35, 41 and 7 other types
● Bivalent (“two type”)- Cervarix
● Protects from 16, 18
● Partial protection from 33 & 41

29. What you should know about
vaccination
● How does the vaccine work?
It gets your body to produce antibodies
against the HPV virus. These antibodies
protect your body from an HPV infection by
fighting the virus when it tries to attack the
cervix.
● Who should take the vaccine and when?
Ideally, the vaccine should be taken as early
as possible after the age of 9 years but girls
and women of any age up to 45 can benefit
from this vaccine.
Expectant mothers should not take the
vaccine during their pregnancy.

30. What you should know about
vaccination
● What is the dose schedule of the vaccine?
The quadrivalent vaccine is given in three doses as follows:
Now 2 mths 6 mths
I I I
In special cases ( ex: impending marriage or travel, planning a pregnancy soon etc.), the
doctor can "abbreviate" the schedule to 0,1 and 4 months.
The bivalent is given in a similar schedule at 0,1 and 6 months.
● How soon will the protection work?
Usually, the full protection comes into effect usually within a month of the last dose. It is
important to complete the schedule.
● How long will the protection last?
So far the data has shown that vaccinated women have been significantly protected from
the disease since they got the vaccine (8.5yrs according to published data). There is a good
chance of life-long protection as well. Only time will tell.
This is being tracked worldwide till we know for sure when people would need a booster, if
at all.
● What about side effects?
The vaccines have been studied and is safe and well tolerated.

31. What have you learnt today?
● Cervical Cancer is the most common cancer affecting
Indian women
● It is a preventable disease
● You can protect yourselves and your daughters and be
almost 100% safe with a combination of vaccination and
screening

32. Thank you