Key Point The CIN grading system classifies dysplasia into 3 categories based on histological changes. Although CIN caused by HPV infection often clears without treatment, the likelihood of progression to invasive cancer is greater in more severe grades (CIN 2/3). Background The CIN grading system classifies dysplasia into 3 categories based on histological changes: CIN 1 includes mild dysplasia and condyloma (anogenital warts), CIN 2 includes moderate dysplasia, and CIN 3 includes severe dysplasia and carcinoma in situ (CIS). 1 These lesions are graded based on the extent of abnormal proliferation of the basal layer of the cervical epithelium. In mild dysplasia (CIN 1), proliferation occurs up to the lower third of the epithelium. In moderate dysplasia (CIN 2), proliferation occurs up to the upper two thirds; and in severe dysplasia/CIS (CIN 3), the entire epithelium is abnormal. 1 When stratified into the various grades of severity, the composite data from a review indicate that the approximate likelihood of regression of CIN 1 is 60%, persistence is 30%, progression to CIN 3 is 10%, and progression to invasion is 1%. The corresponding approximations for CIN 2 are 40%, 40%, 20%, and 5%, respectively. The likelihood of CIN 3 regressing is 33% and progressing to invasion greater than 12%. 2 References 1. Bonnez W. Papillomavirus. In: Richman DD, Whitley RJ, Hayden FJ, eds. Clinical Virology . 2nd ed. Washington, DC: American Society for Microbiology Press; 2002:557 – 596. 2. Ostor AG. Natural history of cervical intraepithelial neoplasia: A critical review. Int J Gynecol Pathol . 1993;12:186–192.
Clinical manifestation & mgt of cancer of the cercix
Clinical Manifestation andManagement of Cancer of theCervix-Lesotho & Developing countries Sejojo Phaaroe,.M.T,;C.T(I.A.C); M.I.B.M.S; A Clinical Cytologist
PHILOSOPY• IF WE DON’T LEARN WE WILL SHRINK AND DIE• IF WE DON’T SHARE WE WILL FORGET THE LESSONS• IF WE FORGET, WE WILL CONTINUE TO REPEAT THE MISTAKES• IF WE LEARN AND SHARE WE WILL GROW AS A TEAM• THE KEY BENEFICIARIES OF THIS FORUM ARE ALL CARE GIVERS AND AFFECTED PEOPLE IN THIS COUNTRY
C A N IT B E S O LV ED By Cytologists by MEDICAL TEAM ? By us all in here ? – yes!
P s y c h o lo g ic a l B io lo g ic a l/ C o u n s e li n g S o c ia l M e d ic a l C o n f li c t R e s o lu t i o n S tre n g th e n - P h a rm a c o - F a m i ly W H A T K IN D T h e ra p y C o m m u n it y O F S O L U T IO N ? E c o n o m ic E d u c a tio n L e g i s l a t iv e (la w ) N ew Jobs F in is h e d O u t la w F i r e a r m sH ig h S c h o o l M o r e P r is o n s / L o n g e r S e n te n c e s
ESTABLISHMENT OF CERVICAL CANCER SCREENING POLICY IS THE ONLY RESOLUTION TO THE PROBLEM IN LESOTHO• By S. Phaaroe - July2004 Seboping Radio Les• S. Phaaroe LMA Journal April 2005• Dr Cronje – Sebeta Memorial Lecture- LMA AGM 2006- ( The financial Muscle I contacted which was willing to give financing into the problem of Cervical cancer in Lesotho said the was no infrastructure for the implementation of the intervention programme”• Dissemination of study of incidence of CACX Lesotho-–S.Phaaroe.LAF- SAHCS-LMA forum- 30/09/2006
FACT FACTORYBOYS LBCN OFFICIAL LAUNCHINGBREAKING THE SILENCE PINK ALL OVER
S. Phaaroee MM.T National stake holders S. Phaaroee .T C.T(IAC), AIBMS C.T(IAC), AIBMS PSBH- REPORT BostonEducation/Information-Magnitude of cancer cx PSBH- REPORT Boston University 2005 University 2005 Well women Well women groups/ church/ groups/ church/ Gyaenacology, Gyaenacology, women in Law, women in Law, Oncology, Oncology, every body, every body, Radiology, Radiology, Support groups/ Support groups/ Pharmacy etc Pharmacy etc men leagues men leagues Chiefs, local Chiefs, local government, government,FAMILY H, ED, FAMILY H, ED, CYTOPATHOLOGY village councils, CYTOPATHOLOGY village councils,PLANNING & PLANNING & BIOMEDICAL NETWORKS BIOMEDICAL NETWORKSMen’s clinics, Men’s clinics, SCIENCE SCIENCEprivate clinics RESEARCH LAB RESEARCH LAB private clinicslinkage with is the central Technology Technology linkage with is the centralNGO’S in aahealth organ INCUBATION INCUBATION NGO’S in health organsystem CENTRES, CENTRES, system SMME’s , ,Joined SMME’s Joined Bilateral Bilateral LEGAL commissions/ commissions/ Education , , Education LEGAL Academic centers SYSTEMS, Policy SYSTEMS, Policy EMPLOYMENT agreements EMPLOYMENT agreements Academic centers of excellence & makers, makers, FORCE/ FORCE/ of excellence & other Research International International Government Government other Research institutions conventions, conventions, Institutions Institutions institutions Regional Regional Insurance Levy, Insurance Levy, strategies strategies & Industry & Industry
Etiological factors behind cancer of the Cervix .Hormonal• women -Early coitus contraceptives• Multiparious women /preparations like depo [Stern et al 1977]• Multisexual partners • STI’s- infection, etc.• It varies with race [genetic • Viral HIV, susceptibility ,etc] • Viral HPV,• High in low socio- economic stata • Viral H Herpes [malnutrition,poor health • Smoking [TARR/hetero] facilities] • Alcohol drinking• Poor hygiene[smegma • Drugs (Diethylstilbestrol- factor] DES),cyclophosphamide• Sperm factor[acridine • Pelvic irradiation. histones] • History of cancer from• Women with boyfriends other sites e.g uterus, with CA. penis colon.
bophelong ba ‘M’eBonyaneng- YouthBoroetsaneng-PurbertyBo ‘M’eng- AdulthoodBoQhekung – PostMenopause
Situation in Lesotho• Lesotho & other developing countries have been unsuccessful in implementing C.C.S.P• Barriers : Insufficient Infrastructures• Inadequate RX for precancerous & cancerous cases• Cost effective approach was to target high peak age of cacx cases ten yrs before invasive CACX• Problem observed was that in Tygerberg the peak up incidence is at 25 yrs for CIN 3• Also supported by Learmonth et.al SAMJ Vol 85 pg 52 Jan 1995. And Lesotho is no different• The possible shift is as a result of incidence of HIV• Screening of all at risk women in the population is targeted• Perform Treatment of only severe Dysplasia
GARDASIL® (Quadrivalent Human Papillomavirus [HPV Types 6, 11, 16, 18] Recombinant Vaccine) Confirmation method Classification of Histological Findings CIN 1/LSIL CIN 1/LSIL CIN 2 /HSIL +HPV (mild (moderate CIN 3 /HSIL Invasive CIN1 Normal (condyloma) dysplasia) dysplasia) (severe dysplasia/CIS) Cancer Histology of squamous cervical epithelium1 Basal cell Basal membrane CIN caused by HPV can clear without treatment; however, rates of regression are dependent on grade of CIN.- With HIV infection the rate can not be predicted
LSIL HSIL HSIL HIV has caused a shift in regression
Clinical Staging of CACX• Precancer: Dysplasia- a degree of epithelial abnormality occurs when normal cells undergo bad changes but too early to be called malignant, however if the condition is left untreated will progress to cancer. CIN 1, 2, and CIN3• There is no agreement over the progression rate• Stage CA CX 1.O = CAO= CIN3/CAO= confined to surface epithelium• CACX stage 1.A= Less or equal < 5mm invasive beyond stroma= micro-invasive CACX• CACX stage 1.B= > 5mm invasive beyond stroma• Stage CACX 2. A = Spread beyond CX• CACX 2.B =Early para-metrium invasion
Stage CACX 3• More Extensive spread• CACX 3.A = Involves lower third of vagina• CACX 3.B= Parametrium and pelvic side wall metastasis• STAGE CACX 4• Extension to bladder• Rectum• True pelvis• Distant organs
Classification of Cancer of the cervix• 90% squamous of the cervix• A) keratinizing squamous carcinoma[good]• B)non keratinizing[poorly differeniated sqcacx[p]• C)small cell squamous carcinoma [WORSE]• 3%Adenocarcinoma of cervix• 2% Adeno-squamous of cervix• 2% Adenoacanthoma of cervix• 3% Clear cell carcinoma of cervix• The cancers respond differently to treatment so prognoses, and type of treatment varies
Signs and symptoms/ clinical presentation• Early signs:• Abnormal vaginal bleeding which could be• Intermenstrual• Post coital bleeding• Post menopausal bleeding• Watery offensive vaginal discharge• The cervix is friable , hard with contact bleeding on examination( the dysplastic cells have poor cohesiveness, so the underlining vascular system in the lamina propriae become exposed.)• The Cytologist should expect micro-biopsies or an inadequate smear scraping because of blood• The Clinician should blot the blood with 5%CH3COOH
Late signs• Pain• Dyspareuria(pain during intercourse)• Urinary symptoms: frequency in urination• Dysurea• Hematuria• Vesico-vaginal and or recto-vaginal fistula• Anaemia, Cachexia• Bone pain, due to metastases
Investigations and Laboratory Diagnoses of advanced cancer• General physical examination by Nurses/Doctors• Pap smear –CYTOLOGY• PCR-for HPV [DNA/RNA]• Biospy for Histology- Cone• Colposcopy• FNAB –cytology of pelvic masses or suspicious Lymph nodes• Molecular biology & Cell markers e.g CEA,EMA• Radiological studies: - Chest X-ray for any Lung Metastases,bone etc• Excretory Urogram- to determine urinary function• Cytoscopy- to exclude bladder involment• Blood Tests: FBC, -
Treatment of Advanced Cancer of The Cervix• Types of Treatments available• Cone biopsy-Lesotho• Surgery(TAH.B.S.O)--Lesotho• Laser Beam Therapy• Radiotherapy• Rarely Chemotherapy• The choice of RX depends on the size of the tumor, patient’s age and general health fitness• Treatment varies on oncology center to center• Stage 1.0: uterine function is conserved, CONE BIOPSY, or Laser therapy is used• Hysterectomy, only conservation of ovaries in patients under 40 yrs( as ovarian hormones are still of value
TREATMENT OF STAGES 1-4• CACX 1A: Hysterectomy only• 3 radium insertions are done if the patient is still fit for surgery• CACX 1.B: Radium and lymphadenectomy• CACX 2..A: as for 1.B but external beam therapy if the tumor is very large( to shrink the tumor)• CACX 2.B: 1º rx Radiotherapy to reduce tumor bulk – external and internal radiation,and this is followed by Radical hysterectomy in selected patients• CACX 3. As for stage 2.B• CACX 4: a) rx is of PALLIATIVE(symtopms which occur)• b) Urinary diversion or colostomy where indicated is done to obviate or because of fistula
The “Total” Pain Concept Emotional •Loss of function •Coping abilitiesSpiritual•Guilt PAIN Financial •Direct costs•Why me?•Life closure •Indirect costsissues Physical •From disease •From treatment
Chemotherapy• It is not effective and popular• Various trials are being carried out at Groote schuur• Drugs commonly used are• Cyclophosphamide• Cisplatiunum• Adriamycin• Melphalan• Special drug monitoring facilities need to be inplace to be able to administer these drugs• Cyclophosphamide is also known to be carcinogenic to the Kindeys & Bladder• It is also a drug of choice for HPV infections
Surgery• General Nursing care is important• Pre & post operative care and counseling• Specific colostomy• Urostomy care are highly needed to effect better results
Radiation therapy[internal radium]• Preparation of the Patient :• Patient is Admitted 12-24 hrs prior to insertion• During this time , a full medical and nursing history will be taken and routine investigations include• Full blood count, temperature, pulse, respiration & blood pressure, urinalyses, chest X-RAY• Consent has been given by the patient• The Oncology nurse should also take time to explain the procedure and its implications to the patient as well as answering any questions the patient may wish to ask• Special sensitivity is needed when dealing with premenopausal patient, as hysterectomy will render them unable to bear children
Radiation therapy Cont----• It is not obvious that treatment by irradiation will produce sterility. This needs explanation to both husband and wife and may increase anxiety already present as a result of a diagnoses• The patient will need to know why visits from the nursing staff and relatives must be restricted so that she does not feel isolated or deserted & this must be repeated many times• The evening prior to insertion the patient should have a thorough shave and the bowels opened by means of of suppositories or an enema• Night sedation will usually be given to ensure adequate rest, and the patient is maintained nil per month from the night before the procedure• Premedication is given before the patient leaves to Theatre.
Insertion of applicatiors.Available information is there on request- From Sejojo Phaaroe mainly for oncology nurses Surgical oncologists , Radiologists gyaenacologists and Cytologists
Use of Inexpensive treatment• Out patient treatment techniques such as Cyotherapy can provide 80-90% cure of CIN3 without sophisticated use of Colposcopy• Rx of only severe dysplasia will increase overall cost effectiveness• Lazar beam therapy• Cone Biopsies also give a treatment and diagnostic pathway• This stress the need for High population screening• Screening for HPV, and HIV to identify women at high risk for developing Cancer of the CX• PAP test is the only cost effective screen for HPV
Spread of cancer of the Disease• Like a CRAB, the lesions tends to spread in all directions• Into the vagina by direct extension• Upwards into the body of the uterus –direct• Laterally into the parametrium, i.e. connective tissue surrounding the uterus• Into adjacent organs i.e., bladder & rectum• Via the Lymphatic to regional lymph nodes• Via Pelvic veins to Liver, Lungs, and bones• Haematogeneous dissemination• Expect to find the CERCIX cancer cells every where• This express the need for establishment & advancement of systemic FNAB cytology services
Recommendation from Sejojo and co- worker’s Lesotho documents• Education of Policy makers about the problem of CACX and importance of PAP TEST screening• Ed. On modalities of follow up and treatment• Establish how feasible, public health oriented approaches to prevent/reduction of incidence & mortality CQI TEAM• Efforts should focus on Research into the extend of the problem and establishment of pilot projects to test the feasibility of CACX screening and treatment in a given setting(Pap test,HPV serotypes in Lesotho,Vaccine development)• Establish limited screening programmes that target High risk women for frequent screening [Discuss infrequent• Establishment of limited treatment programmes that target high risk women for frequent screening[Discuss infrequent• Establishment of a National Cancer Policy and Registry- A Bill and an Cervical cancer screening ACT 2008 eg.
Notifications and Information flow about cancer –
Improvement of efficacy and accuracy of Cytology services• Establish & improve Country training programmes for Clinical Cytologists to required International status• Establish & improve Country training programmes for Oncology nurses and clinicians• Initiate improved Histological diagnoses of all suspected lesions before, by strengthening Lab capacity, independence from diagnostic lab and budgets• Authorities & Decision makers commitments