1. CERVICAL
CANCER???...
THIS IS DONE
BY:
S.DHARSHINEE
GOOD
SHEPHERD
1 INTERNATIONA

2. WHAT IS CERVICAL CANCER???
 It is a cancer which occurs in the cervix of a women.
 Cervical cancer begins in the cervix.
 The cervix is the lower part of the womb, called the
uterus.
 It opens to the vagina. Cervical cancer was once the
number-one cause of death from cancer in women.
 Thanks to the Pap test, which can screen for this
cancer, the number of women in the United States with
cervical cancer has decreased dramatically.
 With the Pap test, doctors can also find changes in the
cervix when they are still precancerous.
 It is the only gynecological cancer, currently, that can be
prevented through routine screening.
2

3. WHAT IS A FEMALE REPRODUCTIVE
TRACT???
• Vulva
• Vagina
• Cervix
• Uterus
• Fallopian tubes
• Ovaries
3

4. WHAT IS A CERVIX????
• The cervix is one part of your
reproductive system.
• It is the lower part of your
womb, also called the uterus.
• The cervix connects your
uterus and vagina.
• And your vagina leads to the
outside of your body and the
vulva, which is the skin area
where you have pubic hair.
• These are the other parts of
your reproductive system.
• They are all in your pelvis.
4

5. IS CERVICAL CANCER VERY COMMON? LETS
SEE HOW COMMON IT IS…..
 500,000 women worldwide die of cervical cancer
annually
 50-60 million women in the U.S. have a Pap test
each year
 3-5 million women in the U.S. have an abnormal
result
 12,200 new cervical cancers diagnosed in the
U.S. per year
 4,100 deaths from cervical cancer in the U.S.
per year.
5

6. THE SYMPTOMS OF CERVICAL CANCER
 Unusual discharge from the vagina.
 Blood spots or light bleeding when you're not
having your periods.
 Bleeding after menopause.
 Bleeding or pain during sex.
 Anemia because of abnormal vaginal bleeding.
 Ongoing pelvic, leg, or back pain.
 Urinary problems because of blockage of a
kidney or ureter.
 Bleeding from the rectum or bladder.
 Weight loss.
6

7. WHAT CAUSES CERVICAL CANCER???
The main cause for cervical cancer is a virus
called (HPV)human papillomavirus….
• HPV is sexually transmitted
• The HPV detected today could have been acquired
years ago
• There are many different types of HPV
 Low-risk types can cause warts
 High-risk types can cause pre cancer and
cancer of the cervix
7

8. HOW COMMON IS HPV(HUMAN
PAPILLOMAVIRUS)????
 Most men and women who have had sex have been
exposed to HPV
 More than 75% of sexually active women tested have
been exposed to HPV by
age 18-22….
 Some doctors think it is almost as common as the cold
virus.
 In the United States, over 6 million people (men and
women) get an HPV infection every year.
 At least one-half of the people who have ever had sex will
have HPV at some time in their life.
 It is especially common among young people.
 The CDC reported in 2009 that about 45% of women aged
20 to 24 had HPV (there are no tests for HPV in men).
 And among girls aged 15 to 19, about 25% had HPV.
8

9. WHO IS AT RISK OF HPV????
 Women who have ever had sex
 Women who have had more than one partner
 Women whose partner (s) has had more than one
sexual partner
 Women with other sexually transmitted diseases
 Women who do not have Pap tests
 Women with immune problems
 Steroid medications
 Transplanted organs
 Chemotherapy
 HIV
 Women who smoke
9

10. HOW DO I REDUCE MY RISK OF GETTING
HPV???
 Delay onset of sexual activity
 Know your sexual partner
 Do not smoke
 Maintain a healthy diet and lifestyle
 Practice safe sex
GET A PAP TEST DONE…..
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11. GET A PAP SMEAR DONE….
 Strong sensitivity and specificity
 Accuracy of Smear Requires
 adequate sample
 presence of enough inflamation and
dysplasia
 quick fixation of specimen to glass slide
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12. WHEN TO GET A PAP SMEAR…
 1st Pap Smear at age when patient becomes
sexually active (or by age 18)
 Yearly pap smears thereafter
 Others contend that monogamous women with no
history of abnormal pap smears can have them
done every 3 years
12

13. HOW A PAP SMEAR IS DONE???
 Patient asked to lie on her back at edge of exam
table with feet in stirrups
 Metal or plastic speculum is inserted into
vagina to expand the wall of vagina to enable
access to cervix
 Cells are collected using cotton swab, wooden
spatula, or cervical brush and smeared onto
glass slide
 Preservative sprayed to prevent cells from
drying and artifacts from forming
 Slide evaluated by lab technician who looks for
abnormalities in the 50,000 to 300,000 cells on
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slide

14. THE CLASSIFICATION OF THE PAP SMEAR…
 The Class System (I to V)
 The CIN(Cervical Intraepithelial Neoplasia) System
(CIN I to III)
 characterizes the degree of cellular
abnormalities
 The SIL( Squamous Intraepithelial Lesion) System
(Bethesda System)
 Lesions characterized as LGSIL(Low Grade
Squamous Intraepithelial Lesion) or
HGSIL(High Grade Squamous Intraepithelial
Lesion)
 Presence of HPV noted
 This scheme is most widely used system
these days 14

15. THE EVALUATION OF THE PAP SMEAR…
 First, the smear is evaluated for adequacy of
sample
 Secondly the sample is categorized as “normal”
or “other”
 Lastly, all sample categorized as “other” are
further specified as infection, inflammation, or
various stages of cancer
15

16. DURING OR BEFORE THE PAP SMEAR ONE SHOULD
FOLLOW THE THINGS LISTED…
 No douching or usage of vaginal
medications, lubricants, or spermicides within
2-3 days of exam (these products may hide
abnormal cells)
 Schedule Pap Smear between days 12-16 of
menstrual cycle, if possible
 Abstain from intercourse 1-2 days prior to
smear
16

17. SOMETIMES THERE IS A PITFALL DIAGNOSTIC
OF CERVICAL CANCER…
 30% of cases of cervical cancer are
missed due to errors interpreting results
of pap smears
 Ways of Improving Pap Smears
 rescreen portions of slide deemed
negative to reduce false-negatives
 new liquid smears may be have higher
sensitivty and specificity
 usage of computerized devices to analyze
smear (PAPNET, VIRAPAP) 17

18. ACCESS TO PAP SMEAR…
 50% of patients who die of cervical cancer have
never had a Pap Smear
 Uninsured, minorities, older patients and those
who live in rural areas have limited access to
Pap Smears
 These groups must be targeted to further
reduce rates of cervical cancer in the US
18

19. WHAT IS A PAP TEST????
 A test which collects cells from the surface of
the cervix and looks for any abnormal cells
 Abnormal cells can be treated before cervical
cancer develops
 When cancer is detected early, it is easier
to treat
19

20. HOW OFTEN SHOULD I HAVE A PAP TEST
DONE???
• Every year until age 30
• After age 30, if you have only had normal
results, you may have them every two to three
years after discussion with your physician and
evaluation of your risk factors.
20

21. WHY IS A PAP TEST IMPORTANT???
 A Pap test can find treatable changes of the
cervix (precancer) before you have a symptom
or notice a problem.
 Once a problem is symptomatic, it is harder
to treat.
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22. WHICH IS THE BEST TIME TO HAVE A PAP
TEST DONE???
 Schedule your Pap when you are not having a
menstrual period.
 It is best to abstain from intercourse and avoid
use of tampons or douches for two days before
your Pap test
22

23. WHY SHOULD I KEEP TESTING???
 The test is not perfect.
 Changes (abnormalities) may occur since the
last test.
 It may take many years for changes to develop
or be detected.
 Your risk changes if you have new partners.
23

24. WHAT SHOULD I EXPECT WHEN I HAVE
A PAP TEST???
o Feet are placed in stirrups (foot holders)
o A speculum (thin duck-billed instrument) is
inserted into vagina to see the cervix
o You may have brief discomfort which is usually
mild
o You may have some spotting afterward
24

25. HOW DO I GET TO KNOW ABOUT MY
RESULTS???
 You may ask to have a copy mailed to you
 You may call for your results
 If you have an abnormal result, it is extremely
important to follow-up for the recommended testing
 Even after a normal Pap test, it is still important to
report any symptoms of abnormal vaginal
bleeding, discharge or pain to your doctor and call
to be seen right away
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26. IS IT COMPULSORY TO HAVE A PAP TEST IF I
HAD A HYSTERECTOMY???
• If you had treatment for precancer or cancer of
the cervix, you may need a Pap test
• If the cervix was left in place at the time of your
hysterectomy, you will still need Pap tests
• Preventive health care is still important even if
you do not need a Pap test
26

27. AT WHICH AGE CAN I STOP HAVING PAP TEST
DONE???
 The American Cancer Society recommends that
screening stop at age 70, if three or more recent
tests are normal, and there have been no
abnormal results in the last 10 years
 If you are 70 or older with a history of normal
results, you are at very low risk of cervical
cancer and do not need Pap test. If you have
sex with a new partner, this may change your
risk. Talk to your health care provider about if
and when you need a Pap test.
27

28. WHAT IS NEW IN SCREENING AND
PREVENTION???
 Liquid cytology-thin layer cytology
 Combination of HPV test and Pap is now
available for women 30 years of age and older
 Pap test computer reviews
 Vaccines for HPV currently being tested.
28

29. WHAT IS A HPV TEST???
 A test sometimes used to determine if you need further
evaluation
 Cells are collected just like a Pap test
 It checks for high-risk HPV
 An HPV test is sometimes useful to determine if you need
any further evaluation. This is particularly true for the
minimally abnormal Pap tests with atypical squamous cells
of undetermined significance, often abbreviated as ASC-US.
 The HPV test is collected just like a Pap test. In fact, if the
Pap test is collected in a liquid, then the HPV test can be run
on that liquid if the Pap test shows minimally abnormal
results.
 The test checks for high-risk HPV.
 The FDA approved HPV DNA test (DNA with Pap) can identify
13 different high-risk HPV types. About 90% of cervical
cancers are caused by one of these 13 types.
29

30. WHAT HAPPENS IF I HAVE AN ABNORMAL
PAP TEST???
 ASC-US management options:
 HPV testing
 Repeat Pap
 Colposcopy
 ASC-H, LSIL, HSIL, AGC, AIS, cancer
 Colposcopy
 Possibly endometrial biopsy for AGC
 AIS / cancer: referral to gynecologic oncologist
 There is a spectrum of Pap test results from “normal to “cancer or carcinoma.”
In between normal and cancer, there is a range of abnormalities, such as ASC-
US (the abbreviation for atypical squamous cells of undetermined significance)
or LSIL (low-grade squamous intraepithelial lesions) to more significant cellular
changes, such as HSIL (high-grade squamous intraepithelial lesions), AGC
(atypical glandular cells) or AIS (adenocarcinoma in situ).
 The abnormalities called ASC-US sometimes harbor pre-cancer changes, but
most often reflect inflammation, hormonal changes or an infection with the
human papillomavirus. If your Pap test shows ASC-US, any of the following
three management options may be chosen as the next step by you and your
doctor: HPV testing, repeat Pap tests at approximately six month intervals or
immediate colposcopy.
 A Pap test is only a screening test.
30

31. WHAT IS A COLPOSCOPY???
Colposcopy:
Use of a magnifying instrument
Application of a vinegar-like solution
onto the cervix
See abnormalities that can’t be seen
with the naked eye
Feels like getting a Pap test, but lasts
longer. The first step in the evaluation
of an abnormal Pap test is a
colposcopy. Colposcopy is a test that
helps find abnormal areas in the cervix.
This is done in the doctor’s office.
Similar to the examination for obtaining
a Pap test, a speculum will be placed
into the vagina. A nurse or doctor then
applies a vinegar-like solution onto the
cervix and examines the cervix with the
colposcope, which is a magnifying lens
with a strong light. If there are
abnormal areas, a biopsy may be taken.
31

32. WHAT IS A CERVICAL BIOPSY?
Biopsy:
• Removal of a small piece of tissue from the
cervix
• May feel like getting a Pap test or like a
menstrual cramp that lasts a few seconds
During a biopsy, a very small piece of tissue is
removed so that a pathologist can evaluate it under
a microscope to make a diagnosis. Any visible
abnormality of the cervix should be biopsied to
make sure of the diagnosis. Having a biopsy taken
may cause some discomfort, like a menstrual
cramp that lasts a few seconds.
Sometimes, your doctor will also perform an
endocervical curettage, in which a little bit of tissue
will be scraped from the cervical canal in order to
examine it more closely under the microscope.
And, at times colposcopy with biopsies and
endocervical curettage is not enough to find the
explanation for the abnormal Pap test and to make
sure of the diagnosis. In this situation, a conization
32
is performed, during which a larger, cone-shaped
piece of tissue is removed from the cervix.

33. WHAT DOES THE BIOPSY RESULT MEAN?
 Mildly abnormal (CIN I)
 observation preferred
 More abnormal (CIN II)
 treatment
 Precancer (CIN III)
 treatment
 Cancer
 Gynecologic oncology consultation
 The pathologist examines all tissues under the microscope. Similar to what was discussed
earlier for the Pap test, biopsy results can show a broad spectrum with the two extremes being
“normal” and “cancer or carcinoma”. In between, there is a range of abnormalities called CIN I
to III. CIN stands for cervical intraepithelial neoplasia. CIN III is a pre-cancer change. This
means the cells are highly abnormal, but do not yet invade or spread like cancer cells.
 It is important to understand that treatment depends on the biopsy results, NOT the Pap test.
 For CIN I management options include treatment or observation. Which route of management is
right for you will depend on a number of factors. Observation is often preferred over immediate
therapy since the chance that CIN I spontaneously regresses to normal is about 60%.
However, about 10% will progress to more severe abnormalities. Therefore, a schedule of repeat
examinations will be needed when CIN I is diagnosed, often Pap tests every six months.
 CIN II and III should always be treated.
 If any invasive cancer has been found, you should be seen by a gynecologic oncologist to
determine what treatment you will need.
33

34. WHAT ARE THE TREATMENT OPTIONS FOR
CIN???
 LEEP
 Laser
 Cryotherapy
 Cone Biopsy
 In special circumstances a hysterectomy may be
recommended
 If you need treatment for CIN, there are multiple treatment
options such as LEEP, laser, cryotherapy, and cone biopsy.
 Options can be divided into two main groups: those that
remove the area of abnormality (LEEP, cone biopsy) and
those that destroy the area of abnormality
(cryotherapy, laser vaporization).
 Each of those have their indications, advantages and
disadvantages, but, importantly, cure rates are comparable.
 In special circumstances a hysterectomy may be
recommended.
34

35. WHAT CAN I EXPECT AFTER TREATMENT FOR CIN(
CERVICAL INTRAEPITHELIAL NEOPLASIA)???
 Estimates of cure range from 73-90% with a single treatment
 The risk for invasive cancer following treatment is about 1%
 Therefore, you still need to have regular Pap tests
 Minimal, if any, impact on fertility
 Cryotherapy, LEEP, laser and conization are similar in their ability to
treat CIN. Estimated cure rates range from 73% to 90% with a single
treatment. However, 10% to 27% of patients will have future problems
with CIN, making close follow-up after treatment very important. Once a
patient has been treated for CIN, her risk for developing invasive
cervical cancer is about 1%.
 One major concern regarding treatment of cervical pre-cancers has
been the potential that fertility may be decreased. Treatment of CIN
could make it more difficulty to get pregnant or to carry the baby to full-
term.
 This could happen because of cervical stenosis (scarring of the opening
of the womb), decreasing cervical mucous formation or cervical
incompetence (weakening of the cervix with difficulties of holding the
baby inside the womb until term). However, there is little evidence that a
single treatment leads to changes of either fertility or pregnancy
outcomes. 35

36. WHAT YOU CAN DO?
Take Control - Protect Yourself
 Ask your doctor about an appropriate Pap test
screening interval for you
 Make sure that you get a Pap test at the
recommended time
 Find out how and when you will learn about the
results of your Pap test
 Follow-up! Don’t assume that no news is
good news
 Do not smoke.
36

37. WHAT ARE THE SYMPTOMS OF CERVICAL
CANCER???
 Abnormal bleeding
 Between periods
 With intercourse
 After menopause
 Unusual vaginal discharge
 Other symptoms
 Leg pain
 Pelvic pain
 Bleeding from the rectum or bladder
 Some women have no symptoms
37

38. WHAT SHOULD I DO IF I HAVE JUST BEEN
DIAGNOSED WITH CERVICAL CANCER???
 Find a gynecologic oncologist
 Discuss treatment options
 Conization
 Hysterectomy
 Radical hysterectomy
 Radiation with chemotherapy
 Ask about clinical trials
 Other considerations
 Preserve your fertility
 Preserve your ovaries
 Often times cervical cancer is first diagnosed by a primary care provider. Once the
diagnosis is suspected or confirmed, the primary care provider will help find a
gynecologic oncologist. These physicians are expert in the diagnosis and
treatment of cervical cancer.
 Women with cervical cancer are encouraged ask about clinical trials. Co-operative
group trials are performed at many institutions around the country and your
gynecologic oncologist can suggest appropriate trials.
 Radical hysterectomy and chemoradiation are the most common treatments for
cervical cancer. Even with a diagnosis of cervical cancer, a woman may have the
option of preserving her ability to have children and to keep her ovaries.
38

39. CLINICAL STAGING OF CERVICAL CANCER…
The clinical stage is the extent of cancer at the
time of diagnosis. Staging is necessary so that
physicians can accurately communicate with
each other about the disease. This allows
doctors to discuss treatment options, to
consider enrollment in clinical trials and to
compare the outcomes in efforts to improve
quality of care. Clinical staging is completed
before treatment begins.
Cervical cancer can be broken into 4 general
groups.
Stage I
Stage IA cancers are cancers with minimal
invasion that can only be detected
microscopically.
Stage IB cancers are those that involve only the
cervix. The cancers that are larger than 4 cm are
classified as stage IB2.
Stage II
A stage IIA cervix cancer indicates that there has
been spread of the cancer to involve both the
cervix and upper portion of the vagina.
A cancer is defined as stage IIB if there is
extension of the cancer into the tissue next to
the cervix.
Stage III
A stage IIIA cervical cancer has involvement of
the lower vagina and a IIIB has extension of the
cancer towards the pelvic sidewall.
Stage IV
Stage IV cancers involve the
bladder, rectum, lungs or other organs. 39

40. WHAT IS A CERVICAL CONIZATION?
Conization:
•Removes a cone-shaped piece of
tissue
•Often allows for diagnosis and
treatment
•Performed with local anesthesia in
the office or under general
anesthesia in the operating room
A cervical conization is often used to
diagnose or exclude the presence of a
very small cervical cancer. This
procedure is performed in the operating
room with or without general anesthesia
where a cone shaped segment of the
cervix is removed.
Alternatively a large cervical excisional
biopsy can be performed in the office
under local anesthesia.
The risks associated with a cervical 40
conization are bleeding, infection and
infertility.

41. WHAT IS A RADICAL HYSTERECTOMY???
 Treatment option for early stage cancer
 Not the same as the usual hysterectomy
 Surgical removal of the uterus, cervix and upper vagina with the
surrounding tissues
 Lymph nodes are removed
 Removal of the ovaries is not required
 If a hysterectomy must performed for the treatment of cervical
cancer, a radical hysterectomy is usually performed. This involves
removal of the uterus along with a portion of the surrounding
support tissue and a portion of the upper vagina. The lymph nodes
in the pelvis and sometimes those near the aorta are removed.
 The radical nature of the procedure results in a few more
complications when compared to a simple hysterectomy. The most
common changes are noted in the function of the bladder (you can’t
tell when your bladder is full, so you must watch the clock to know
when to go), shortening of the vagina and constipation.
 A radical hysterectomy does not require removal of the ovaries.
41

42. WHAT IS RADIATION WITH
CHEMOTHERAPY (CHEMORADIATION)???
 Standard of care for advanced cancer
 Treatment requires:
1. External radiation
2. Internal radiation
3. Low dose chemotherapy given at the same time
 For some women, treatment with chemoradiation is a better option
than surgery. This is most often true with advanced cancer.
 Radiation is composed of two portions, external and internal
radiation. A very low dose of chemotherapy is administered at the
same time as the external radiation. This low dose of
chemotherapy makes the radiation therapy more effective.
 External radiation is usually given in small doses five days a week
for about five weeks. Fatigue, nausea, diarrhea, and skin or vaginal
irritation are common side effects.
 For internal radiation, a radiation cylinder is placed inside the
vagina where it delivers radiation treatment directly to the cervix.
This procedure can last several hours to a full day in the hospital.
Two to three treatments may be necessary. 42

43. CERVICAL CANCER: WHAT IS THE CHANCE OF
SURVIVAL AFTER TREATMENT???
FIGO Stage 5-Year
The survival rate five years
after diagnosis varies
Survival
depending upon the stage of Stage I 81-96%
cervical cancer. The risk
increases with higher stages
of disease. However, there Stage II 65-87%
are treatment options for
everyone.
Stage III 35-50%
Stage IVA 15-20%
43

44. RE-ESTABLISHING WELLNESS…
 Restoring wellness is a gradual process
 Some women find strength from:
 Friends and family
 Support groups
 Spiritual work
 Counseling
 Exercise
 The challenges and the journey are different for
each woman with cervical cancer
44

45. HOW DO I GET MY FRIENDS TO HAVE A PAP
TEST???
 Tell her it doesn’t hurt
 Offer her a ride
 Offer help with child care
 Help her get an appointment
 Help her find the right health care provider
 Empower her with information: Tell your friend about the
importance of health prevention
 The most important thing that any woman can do to prevent
cervical cancer is to have a Pap test regularly! It is very important
to educate our friends about the importance of a Pap test.
 There are many reasons women postpone having a Pap test.
 Help your friend by reassuring her that a Pap test does not hurt.
 Give her a ride to get the Pap test.
 Offer to help with child care.
 Help her identify a health care provider or clinic so that she can
make an appointment for her Pap test.
45

46. DOSES OF THE VACCINE…
 There are totally 3 doses
 Second dose is followed by the first dose after
two months
 The third one is also vaccinated after two
months from the second dose
 The third one is a bit painful but ignorable…
46

47. SOME PICTURES OF CERVICAL CANCER….
47

48. CONTINUATION OF THE PICTURES….
48

49. PICTURES OF HPV…..
49

50. THANK YOU FOR LOOKING INTO THIS
PPT….
Take a vaccine and
enjoy your life…
THIS IS DONE BY:
S.DHARSHINEE
GOOD SHEPHERD
INTERNATIONAL 50
DONE ON SCHOOL
26/6/2012

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