CERVIX CANCER FOR PHYSICIANS

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VISAKHAPATNAM,1/7-MVP[AP]
1

Dr.KANHU CHARAN PATRO
M.D,D.N.B [RADIATION ONCOLOGY]
FAROI[USA],PDCR[CLINI.RESEARCH]
CBB[HOSP.Mx]CEPC[PALL.CARE]
EX-RESIDENT TATA MEMORIAL HOSPITAL
HOD,RADIATION ONCOLOGY
MAHTMAGANDHI CANCER HOSPITAL & RI
M +919160470564,+919581062264
E mail-drkcpatro@gmail.com

 Cancer is the second leading cause of death.
 Globally, By 2020, there will be 20 million new cancer patients
each year.
 In the U.S., there are 1.25 million new cancer cases annually
 198,100 prostate  192,200 breast
 169,500 lung  135,400 colorectal
 In 2001, U.S. cancer mortality will be about 553,400 --over
1,500 people a day.
 In the US, men have about a one in two lifetime risk of
developing cancer; for women the risk is about one in three.
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Radiotherapy
X ray
Surgery
PET
MRI
Chemo
? ?
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Oncologist
Diagnosis
Treatment
Radiologist
Cytopathologist
Surgeon
Histopathologist
Molecular
Pathologist
Geneticist
psychiatrist
Nursing
And
Support staff
Audit

 Surgical.
 Radiotherapy.
 Radiotherapy & Surgery.
 Radiotherapy and Chemotherapy followed by
Surgery.
 Palliative treatment.

 Fitness of the patients
 Age of the patients
 Stage of disease.
 Type of lesion
 Experience and the resources avalible.

 Mediacally inoperable
 Stage II-IV disease
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 Bladder related
 Rectum related
 Bowel related
Acute
Late
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-PelvicExenteration
- Neoadjuvant chemotherapy or concurrent chemoradiotherapy
- Palliative Radiotherapy
 Surgical Exenteration : Selected patients of stage IV, with no or minimal
parametrial invasion may be treated with primary exenterative surgery, the extent of
which (anterior, posterior or total) would depend on the extent of the lesion.
 Neoadjuvant chemotherapy or concurrent chemoradiotherapy
Selected patients with good general and renal status and not suitable for surgical
exenteration can be treated with this approach with radical intent.
 Palliative Radiotherapy: The majority of stage IVA patients has poor general
condition and extensive local disease in our setting and are best treated with
palliative radiation therapy alone. A short palliative regime of 30 Gy in 10 fractions
over two weeks or 30 Gy / 3# / 60 days (10 Gy / every month x 3#) is generally used
and in few patients who respond very well, this is followed by intracavitary
application.
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 Very bulky disease
 With paraaortic node
 Satge IV A disease[bladder and rectum inv.]
2cycle NACT
f/b radiation
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Depends 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%

 I. clinical Examination
◦ 3monthly for first 2year
◦ 6monthly for after 2year
◦ Annually there after
 II. No other investigations in asymptomatic
patients for early detection of metastasis, since it
is -
◦ Not cost-effective
◦ Does not prolong survival.
◦ Detection and disclosure of spread of disease may be
psychologically harmful to an asymptomatic
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 On completion of
treatment all patients
are given a vaginal
dilator to use until
vaginal mucosa
healed, this prevents
vaginal stenosis.
 Premenopausal
patients commenced
on HRT:
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With in 3 month follow up
1.No pap smear/bx
2.Confusion about radiation changes
3.Unnecessary investigation
4.Anxiety
5.Unnecessary treatment

Criteria Grade Recommendation
• Cytology only, 21 to 65 years old A Every 3 years
• Cytology + HPV co-testing, 30-65
years old
A Every 5 years
• Women under 21 years old D Avoid screening
• Age ≥ 65 with adequate prior
screening and not high risk
D Avoid screening
• Total hysterectomy; benign
disease
D Avoid screening
• HPV testing, alone or in
combination, < 30 years old
D Avoid screening
USPSTF Cervical Cytology Guidelines
March 2012

Age Screening
< 21 No Screening
21-29 Cytology alone every 3 years
30-65 Preferred: Cytology + HPV every 5 years* OR
Acceptable: Cytology alone every 3 years*
> 65 No screening, following adequate neg prior
screens
After total hysterectomy No screening, if no history of CIN2+ in the past 20
years of cervical cancer ever
Triple A Guideline: ACS, ASCCP,
American Society for Clinical Pathology
CA Cancer J CLIN March 2012
*If cytology result is negative or ASCUS + HPV negative

Summary of Important Guideline Changes
•1st
time that all 3 organizations involved with
cervical cancer prevention and the USPSTF have
endorsed equivalent guidelines
•Co-testing is “ready for primetime” for women
≥ 30
-But, co-testing every 5 years (NOT
every 3 years)
•Women 21-29: cytology every 3 years (NOT 1
or 2)
•Stop screening women under 21 years of age
•Stop screening women 65 and older if negative
results and adequate prior screening

 There are two HPV vaccines (Gardasil and Cervarix)
which reduce the risk of cancerous or precancerous
changes of the cervix and perineum by about 93%.
 HPV vaccines are typically given to women age 13 to 26
as the vaccine is only effective if given before infection
occurs.
 The vaccines have been shown to be effective for at
least 4 to 6 years, and it is believed they will be effective
for longer; however, the duration of effectiveness and
whether a booster will be needed is unknown
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 Delivered 5 days per week over 6-8 weeks
 Typical treatment takes around 5 minutes
 Treatment is painless--like having an X-ray taken
 No radioactive substances involved; beam goes on/off
 Side effects usually temporary; controlled with
medication/diet
 Covered by Medicare and many other insurance
companies

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Evolution of
radiotherapy
treatment
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Wilhelm Conrad RontgenWilhelm Conrad Rontgen

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TELETHERAPY
BRACHYTHERAPY

 High dose to tumor tissue-Tumor control
 Normal tissue sparing
 Minimize long and short term toxicities
 Better Quality of life
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CONVENTIONAL RT
Collimator shapes Beam
Rectangular Treatment Field
Shaped Treatment Field
1970s and earlier

 Divides each treatment field
into multiple segments
 Modulates beam intensity,
giving discrete dose to each
segment
 Uses multiple, shaped beams
(~9) and thousands of
segments
IMRT
Initiated in 1995
Reached the clinic in
2000

IMMOBILIZATION
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• Uniform dose to simple shapes
• Circa 1930-1960

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Caveman et al
Oops! The target
moves!
IGRT

Electronic Portal Imaging Device (EPID)
iView GT- Electa
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 Short distance /contact with tumor
 Expertise needed
 Invasive procedure
 Adequetly sparing normal structure
 Well established
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HDR ICA APPLICATORS
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Uterine Sound
Foley’s Bulb
Bladder
Picture No. 3
ansabdominal Ultrasonography
Picture No. 5
ICA HDR application
Picture No. 4
US Guided Brachytherapy

MUPIT IMPLANT IN CA CERVIX
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Low dose rate brachytherapy High dose rate

Surgical staging (stages IIB to IVA):
- 25 % para-aortic metastases
- Para-aortic nodal status is the most
significant prognostic factor

 PET/CT is a useful tool in cervical cancer.
 20% of the patients had more extensive disease
than demonstrated with conventional staging.

 Only one scanning procedure
 Precise anatomical localisation and function

 Improved the diagnose
 Para-aortic metastases
 Iliac lymph nodes
 Distant metastases

 Allows dose escalation to the target volume
 Reduce dose to organs at risk

 PET pos LN 64 Gy
 Uterus – before IMRT 46 Gy + 35 Gy BT
 Uterus – with IMRT 50 Gy + 35 Gy BT

 In Radiotherapy, PET/CT optimises
treatment planning by increasing
information about
◦ Staging
◦ Viable tumour tissue
 Important for IMRT

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 Dose: 34Gy in 10 fraction bid
 Dose per fraction: 340cGy

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CT Loading Dose
distribution

TONGUE IMPLANT IN PROGRESS
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METASTASIS- give a smiling death
108

Palliative radiation
Skeletal X-Ray
Bone scan
MRI
PET-CT

Superscan-extensive bone mets
116

CAUTION
C - Change in bowel or bladder habits
A - A sore that does not heal
U - Unusual bleeding or discharge
T - Thickening or lump in the breast or any part of the body
I - Indigestion or difficulty swallowing
O - Obvious change in a wart or mole
N - Nagging cough or hoarseness

Change in bowel habits
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Change in bladder habits
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A sore that does not heal
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Unusual bleeding or discharge
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Thickening or lump in the
breast or any part of the body
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Indigestion or difficulty swallowing
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Obvious change in a wart or mole
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Nagging cough or hoarseness
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Liver cancer-
hepatitis B vaccine

Cervix cancer vaccine
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Promise-Stop drinking alcohol
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Meditation
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139
Dietary protective factorsDietary protective factors

Just “Doing It” is not good enough !
You must know “what” to do and “where” to do it !
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Whenever not
possible,
make friends

CERVIX CANCER FOR PHYSICIANS

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