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GYNAECOLOGY CANCER 
AWARENESS
World 10 most common cancer in 
women (GLOBOCAN 2008) 
Breast 
Colorectum 
Cervix uteri 
Lung 
stomach 
Corpus uteri...
Cervical Cancer 
Third most common cancer in women. 
8.8 % of all female cancer. 
Responsible for a total of 275,000 de...
Uterine Cancer 
6th most common women cancer. 
More than 90 % of patients with uterine cancer are 
more than 50 years ol...
Ovarian Cancer 
Cancer of the ovary is one of the most lethal 
gynaecological malignancies due to late presentation, 
poo...
Risk factors 
Can be considered as sexually transmitted disease. 
Early age of sexual activity predisposes to cervical 
...
Women who are married to a man with multiple 
sexual partners are at a higher risk. 
Cigarette smoking has been identifi...
Prevention 
There are 3 modalities of cervical cancer prevention: 
1. Primary prevention: 
- prevention of HPV infectio...
1. HPV vaccination 
HPV is the primary aetiology of cervical cancer. 
Following the limitations of secondary prevention:...
Oncogenic types of HPV are estimated to cause 
almost 100% of cervical cancer. 
2 potential benefits of HPV vaccination:...
Currently 2 types of prophylactic HPV vaccines 
available in the market: 
- quadrivalent HPV vaccine against HPV 16,18,6...
2. Screening of cervical cancer 
Screening of precancerous lesions and invasive 
cervical cancer is secondary prevention....
- the greatest reduction in the cervical cancer 
incidence was in women aged between 30 and 49 
years, for whom the focus...
The protective effect of 5 years screening interval in 
the organised screening program was still high 
(> 80 %). 
Scree...
Type of screening tests 
1. cytology 
2. visual inspection 
3. HPV testing 
4. others
1. Cytological screening 
2 types: 
1. conventional cytology 
2. liquid – based cytology
Conventional cytology: 
- Pap smear screening program significantly reduced 
the incidence and mortality of cervical can...
- Pap smear is highly specific in detecting invasive 
cervical cancer and HGSIL, but less specific in low 
grade lesions....
Liquid – based cytology: 
- introduced to increase the sensitivity and specificity 
of cervical screening. 
- more posi...
2. Visual inspection 
Direct visualisation of the cervix after application of 
either acetic acid 3-5% or Lugol’s iodine....
3. HPV testing 
HPV DNA is identified in almost all 99.7% verified 
cases of cervical cancer worldwide. 
4 potential rol...
4. Others 
Optoelectronic device - for optical and electrical 
assessment of the cervix to detect any abnormal 
epitheliu...
Presentation 
Asymptomatic at an early stage. 
Abnormal vaginal bleeding = speculum exam. 
Most common - post coital bl...
Pelvic pain, urinary problems and constitutional 
symptoms – strong indication of advance stage 
disease. 
Pyometra – if...
late stage – SOB, bone pain, severe headache, 
neurological problems, LOA and LOW. 
Lymphatic obstruction may result in ...
Type of endometrial cancer 
Broadly classified into 2 main categories: 
Type I endometrial cancer: 
- is related to exp...
Type II: 
- has no association with predisposing factors. 
- example – uterine papillary serous, clear cell 
carcinoma....
Risk factors 
Prolonged exposure to oestrogen. 
High level of endogenous oestrogen is often seen in 
obese women, patien...
DM and HPT – risk factors independent of their 
association with obesity. 
The use of COCP for 1 year decreased the risk...
Smoking is said to reduce the risk. 
Pregnancy has a natural protective effect because of 
high production of progestero...
Risk factors for Type I 
endometrial cancer 
Obesity: 
- >30 lb ideal BW 3x 
- >50 lb ideal BW 
10x 
Nulliparous 2-3x ...
Endometrial hyperplasia: progressing to 
Ca 
- simple hyperplasia (no atypia) 1% 
- complex (adenomatous, no atypia) 3%...
Prevention 
Can be prevented by treating the precursor lesions 
either by hormonal or surgical treatment. 
Adding a prog...
Suggestions of a protective effect of high phyto-oestrogen 
consumption among post menopausal 
women. 
The use of IUCD a...
Pregnancy is a physiological protection, due to a high 
level of of progesterone produced b the placenta. 
The use of CO...
There is no effective screening method for 
endometrial cancer. 
For available methods - accuracy in asymtomatic 
popula...
Presentation 
Majority of patients with endometrial cancer are 
postmenopausal women. 
Most common presenting Sx is PMB....
Ovarian cancer
Epithelial cancer is infrequent below 40 years old. 
Peak rate is at 70 - 74 years age group with the 
incidence of 57/1...
Risk factors 
1. Reproductive factors: 
Parous women have 30 - 60% less risk compared to 
nulliparous. 
The birth of th...
OCP reduces the risk by 30 - 60 %. 
History of breast cancer increases the risk. 
Early menache and late menopause are ...
2. Genetic factors: 
Lifetime risk in general population is 1.6%. 
Increased to 4% in women with a first degree relativ...
The frequency of BRCA 1 mutation is about 1 in 800. 
62% of patients with epithelial ovarian cancer have a 
mutation of ...
3. Environmental factors: 
Incidence highest in industrialised countries except 
Japan. 
Incidence lowest in under deve...
Prevention 
OCP (chemoprevention) has the highest protective 
effect against ovarian cancer. 
Taking OCP for at least 5 ...
Prophylactic oopherectomy to women with BRCA1 
and BRCA2 mutations after the age of 30 - 35 years, 
reduces the risk by 8...
Screening 
There is no effective screening method.
Presentation 
75 - 85% of patients already has peritoneal spread at 
the time of the diagnosis. 
Most common presentatio...
Diagnosis of early stage cancer is usually made by 
abdominal and pelvic examination. 
In premenopausal women, functiona...
Gynaecology cancer awareness
Gynaecology cancer awareness
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Gynaecology cancer awareness

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Gynaecology cancer awareness

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Gynaecology cancer awareness

  1. 1. GYNAECOLOGY CANCER AWARENESS
  2. 2. World 10 most common cancer in women (GLOBOCAN 2008) Breast Colorectum Cervix uteri Lung stomach Corpus uteri Ovary Liver Thyroid Non – Hodgkin lymphoma
  3. 3. Cervical Cancer Third most common cancer in women. 8.8 % of all female cancer. Responsible for a total of 275,000 deaths; 58% were reported from Asia.
  4. 4. Uterine Cancer 6th most common women cancer. More than 90 % of patients with uterine cancer are more than 50 years old. Cancer of the uterus has a much more favourable prognosis than ovarian and cervical cancer with 5 – year survival rates of around 80 – 90 % in developed countries and 70 % in developing countries.
  5. 5. Ovarian Cancer Cancer of the ovary is one of the most lethal gynaecological malignancies due to late presentation, poor respond to treatment and high recurrent rate. 3.7 % of all women cancer; with 4.2 % of all cancer deaths in women.
  6. 6. Risk factors Can be considered as sexually transmitted disease. Early age of sexual activity predisposes to cervical cancer. Relative risk is 2.5 if the age of the first sexual exposure is < 18 years old. Women with hx of HPV infection is also at a higher risk. Women with multiple sexual partners have a relative risk of 2.8 if the no. of partners > 4. Multiparous women are at a higher risk. Women in lower socio-economic class are at a higher risk.
  7. 7. Women who are married to a man with multiple sexual partners are at a higher risk. Cigarette smoking has been identified as a significant risk factor by 2 – 5 folds. Patients who are immunodeficient are at a higher risk. In-utero exposure to DES. Women with uncircumcised sexual partner may be at higher risk.
  8. 8. Prevention There are 3 modalities of cervical cancer prevention: 1. Primary prevention: - prevention of HPV infection either through sexual abstinence, healthy lifestyle and HPV vaccination. 2. Secondary prevention: - detection and treatment of precancerous state through screening. 3. Tertiary prevention: - detection and treatment of an early stage of cancer.
  9. 9. 1. HPV vaccination HPV is the primary aetiology of cervical cancer. Following the limitations of secondary prevention: - 2` prevention does not prevent HPV infection or pre-invasive lesions of the cervix. - lesion that has rapid progression rate may not be detected in time. - higher chances of missing the lesions in the cervical canal. - limited sensitivity and specificity. - high cost and labour intensive.
  10. 10. Oncogenic types of HPV are estimated to cause almost 100% of cervical cancer. 2 potential benefits of HPV vaccination: - prevention of HPV-related precancerous and cancerous lesions. - prevention of HPV-related benign lesions.
  11. 11. Currently 2 types of prophylactic HPV vaccines available in the market: - quadrivalent HPV vaccine against HPV 16,18,6,11 - bivalent HPV vaccine against HPV 16 and 18
  12. 12. 2. Screening of cervical cancer Screening of precancerous lesions and invasive cervical cancer is secondary prevention. It stops the progression of disease once it has already started. Comprehensive analysis of data by International Agency of Research on Cancer (IARC) showed: - well organised screening programs were effective in reducing cervical cancer incidence and mortality.
  13. 13. - the greatest reduction in the cervical cancer incidence was in women aged between 30 and 49 years, for whom the focus of screening was the most intense. Target age range of a screening program was a more important determinant of risk reduction than frequency of screening, within the defined age range. Screening interval every 2 – 3 years have been found to be as effective as annual screening.
  14. 14. The protective effect of 5 years screening interval in the organised screening program was still high (> 80 %). Screening every 2 years is approximately 50% more expensive than screening every 3 years. Risk of developing invasive cervical cancer is 3 – 10 x greater in women who have not been screened. Risk also increases with long duration following the last normal screening test.
  15. 15. Type of screening tests 1. cytology 2. visual inspection 3. HPV testing 4. others
  16. 16. 1. Cytological screening 2 types: 1. conventional cytology 2. liquid – based cytology
  17. 17. Conventional cytology: - Pap smear screening program significantly reduced the incidence and mortality of cervical cancer. - in UK, since the introduction of the organised pap smear screening program in 1988, the incidence and mortality rate of cervical cancer have fallen by more than 50%.
  18. 18. - Pap smear is highly specific in detecting invasive cervical cancer and HGSIL, but less specific in low grade lesions. - pap smear is not very sensitive. Low sensitivity was attributed to poor sample collection, incorrect slide preparation and lab interpretation errors. To reduce the false negative, sample from the endocervix has to be taken. Cytobrush can obtain more cell than Ayre’s spatula and cotton tip applicator.
  19. 19. Liquid – based cytology: - introduced to increase the sensitivity and specificity of cervical screening. - more positive results with LBC. - large reduction in unsatisfactory smear in LBC group. - per test cost of LBC is higher.
  20. 20. 2. Visual inspection Direct visualisation of the cervix after application of either acetic acid 3-5% or Lugol’s iodine. A result is obtained immediately and treatment can be performed at the same time.
  21. 21. 3. HPV testing HPV DNA is identified in almost all 99.7% verified cases of cervical cancer worldwide. 4 potential roles of HPV testing: 1. triage of women with equivocal cytology 2. following up of patient after treatment of CIN 3. HPV testing in “see and treat” approach 4. HPV testing as primary screening test
  22. 22. 4. Others Optoelectronic device - for optical and electrical assessment of the cervix to detect any abnormal epithelium. New technologies: - HPV genotyping - HPV mRNA - HPV viral load - HPV integration
  23. 23. Presentation Asymptomatic at an early stage. Abnormal vaginal bleeding = speculum exam. Most common - post coital bleeding. Passing out blood stained mucus. Pelvic pain. Copious foul smelling PV d/c. Constitutional symptoms.
  24. 24. Pelvic pain, urinary problems and constitutional symptoms – strong indication of advance stage disease. Pyometra – if the d/s has obstructed the uterine outflow tract. Presents with pelvic pain, purulent vaginal d/c and fever. Invasion posteriorly may cause tenesmus and PR bleeding.
  25. 25. late stage – SOB, bone pain, severe headache, neurological problems, LOA and LOW. Lymphatic obstruction may result in lower limb lymphoedema. Venous outflow obstruction can lead to DVT.
  26. 26. Type of endometrial cancer Broadly classified into 2 main categories: Type I endometrial cancer: - is related to exposure to unopposed endogenous or exogenous oestrogen. - frequently arise on a background of atypical hyperplasia. - have an association with obesity, nulliparity, insulin resistance and hyperoestrogenism. - usually well differentiated and have a better prognosis.
  27. 27. Type II: - has no association with predisposing factors. - example – uterine papillary serous, clear cell carcinoma. - patients tend to be elderly and thin. - have a poorer prognosis. 80% of endometrial cancer are type I.
  28. 28. Risk factors Prolonged exposure to oestrogen. High level of endogenous oestrogen is often seen in obese women, patients with PCOS and oestrogen producing tumour. 50% of patients has BMI > 25 kg/m2. In premenopausal women, obesity causes insulin resistance, ovarian androgen excess, anovulation and chronic unopposed oestrogen.
  29. 29. DM and HPT – risk factors independent of their association with obesity. The use of COCP for 1 year decreased the risk of endometrial cancers by more than 40%. Women on combined HRT have also been found to have lower risk. About 5% of endometrial cancer is hereditary, a/w a hereditary non-polyposis colon cancer syndrome (HNPCC).
  30. 30. Smoking is said to reduce the risk. Pregnancy has a natural protective effect because of high production of progesterone by placenta.
  31. 31. Risk factors for Type I endometrial cancer Obesity: - >30 lb ideal BW 3x - >50 lb ideal BW 10x Nulliparous 2-3x Late menopause 2.5x Heavy PMB 4x DM 2.8x HPT 1.5x Unopposed exog. E untx complex atypical hyperplasia – 29% will develop adenoCa Tamoxifen 6.4-7.5x
  32. 32. Endometrial hyperplasia: progressing to Ca - simple hyperplasia (no atypia) 1% - complex (adenomatous, no atypia) 3% - atypical simple (cystic w atypia) 8% - atypical complex (adenomatous w atypia) 29%
  33. 33. Prevention Can be prevented by treating the precursor lesions either by hormonal or surgical treatment. Adding a progestogen for at least 10 - 12 days per cycle in HRT. Women with amenorrhoea or oligomenorrhoea (including women with PCOS) should be treated with cyclical progestogen, to avoid prolonged exposure of the endometrium to a high level of oestrogen. Withdrawal bleeding of 3 monthly is sufficient to prevent endometrial pathology.
  34. 34. Suggestions of a protective effect of high phyto-oestrogen consumption among post menopausal women. The use of IUCD and tubal ligation have also been associated with a lower risk. Weight reduction and physical activities to achieve ideal body weight, can reverse the effect of prolonged exposure to a high level of oestrogen.
  35. 35. Pregnancy is a physiological protection, due to a high level of of progesterone produced b the placenta. The use of COCP for 1 year decreased the risk by > 40%. Also known to reduce the incidence of ovarian cancer.
  36. 36. There is no effective screening method for endometrial cancer. For available methods - accuracy in asymtomatic population is limited. In women presenting with PMB, TVS showing ET of 5mm or less and negative endometrial sampling, have nearly 100% negative predictive value.
  37. 37. Presentation Majority of patients with endometrial cancer are postmenopausal women. Most common presenting Sx is PMB. Abnormal PV d/c. abnormal PV bleeding in 80% (including PMB and irregular menses in premenopausal women). Pressure Sx due to uterine enlargement. Sx indicating extrauterine spread.
  38. 38. Ovarian cancer
  39. 39. Epithelial cancer is infrequent below 40 years old. Peak rate is at 70 - 74 years age group with the incidence of 57/100,000 population. Ovarian cancer at the older age group carries a poorer prognosis.
  40. 40. Risk factors 1. Reproductive factors: Parous women have 30 - 60% less risk compared to nulliparous. The birth of the first child reduces the risk by 45%. Every further pregnancy reduces the risk by 15%. Breast feeding reduces the risk. Tubal ligation is also associated with lower risk. Ovulation induction agent increases the risk by 2-3 x, if taken for > 12 ovulatory cycles.
  41. 41. OCP reduces the risk by 30 - 60 %. History of breast cancer increases the risk. Early menache and late menopause are risk factors. Slightly increased risk with HRT.
  42. 42. 2. Genetic factors: Lifetime risk in general population is 1.6%. Increased to 4% in women with a first degree relative affected. Increased to 7% when 2 first degree relatives are affected. 5-10% of all epithelial ovarian ca results from hereditary predisposition.
  43. 43. The frequency of BRCA 1 mutation is about 1 in 800. 62% of patients with epithelial ovarian cancer have a mutation of p53.
  44. 44. 3. Environmental factors: Incidence highest in industrialised countries except Japan. Incidence lowest in under developed and developing countries. High intake of meat and animal fat diet increases the risk. Low fat diet may reduce the risk in postmenopausal women. Obesity has been attributed to risk of ovarian cancer.
  45. 45. Prevention OCP (chemoprevention) has the highest protective effect against ovarian cancer. Taking OCP for at least 5 years reduces the relative risk of by 50%. Tubal ligation and hysterectomy reduces the risk. Prophylactic oopherectomy is often performed together with hysterectomy for benign conditions.
  46. 46. Prophylactic oopherectomy to women with BRCA1 and BRCA2 mutations after the age of 30 - 35 years, reduces the risk by 80%. For women with BRCA1 and BRCA2, recommended to do TVS and CA125 levels every 6 - 12 months, in women age 25 - 35 years old. Genetic testing for BRCA1 and BRCA2.
  47. 47. Screening There is no effective screening method.
  48. 48. Presentation 75 - 85% of patients already has peritoneal spread at the time of the diagnosis. Most common presentation: - abdominal discomfort - abdominal pain and distension - GIT symptoms e.g. nausea, dyspepsia, constipation.
  49. 49. Diagnosis of early stage cancer is usually made by abdominal and pelvic examination. In premenopausal women, functional cyst is rarely > 8cm, and will resolve after 2-3 months without treatment. Adnexal mass in pre-menarchal and post menopausal women has a higher likely hood of being malignant.

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