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BY JIMMY CHIBAYA
CLINICAL TECHNICIAN
 Background
 Definition
 Causes
 Risk factors
 Prevention
 Test/investigation
 Treatment
 Cervical cancer staging
BACKGROUND
 It is one of the leading causes of cancer
related deaths in women worldwide.
 Data for 2018 shown an estimated of 567
847 new cases diagnosed.
 311 365 women died.
 85-90% of these deaths were from low
resource settings.
 Most die at the age of 35-44.
 Highest incidence of cervical cancer occurred
in Southern and East Africa.
 Malawi has highest burden of the disease.
 It has the second highest in the world with
age standardised incidence and mortality
rates at 72.9 and 49.8 respectively per 100
000 population.
 3684 developed cervical cancer in 2018.
 2314 die from the disease
 Is the biological process in which cells grow
without regulation, overwhelming normal
cells and function.
 When diagnosed late or untreated is almost
fatal.
 Cervical cancer originates from cervix with an
HPV infection.
 Can spread to adjacent tissues.
 It can also spread to local lymphatic system.
 In advanced stage can spread beyond the
pelvis.
 It has a pre-cancer stage.
 It is caused by Human Papilloma Virus (HPV).
 Is an easily transimissible DNA virus.
 Has more than 150 subtypes.
 Different HPV types cause infections in
different parts of the body.
 Some cause common skin warts and others in
genital tract.
 Most of the HPV are transient, the body will
clear it.
 91% of the infections clear up within three
years.
 It is frequently spread by intercourse and by
genital skin to skin contact.
 HPV infections are common.
 Studies show that by the time that person has
had three or more sexual partners they have
50% chance of becoming infected with HPV.
 Condom reduces it by 60%.
 Some HPV with high risk types are 16 and 18.
 70% cervical cancers are caused by these 16
and 18.
 HPV 16 is the most oncogenic and cause
almost 50%.
 Being HIV positive makes 4-6 times more
likely to develop into cervical cancer.
 Even if client is on ART.
 They can progress and die quickly.
 Have higher persistent HPV infection.
 Have higher prevalence of HPV.
 Higher rates of infection with multiple HPV
types.
 Age (30-50).
 Initiation of sexual activity before the age of
20.
 Multiple births.
 Multiple partners.
 Previous abnormal screening test results.
 Smoking.
 Superimposed infections; simple herpes virus,
trichomonias etc.
 Immunosuppression.
A.PRIMARY
 The use of prophylatic vaccines.
 Three common vaccines are;
1. Bivalent (HPV 2) protects against HP type
16 and 18.
2. Quadrivalent (HPV4),against 6,11,16,18
3. Nanovalent (HPV9),against
6,11,16,18,31,33,45,52 and 58.
 These are effective when given prior to sexual
exposure.
 In Malawi it recommends girls of 9 to 14
years.
 Malawi use HPV4 (Gardasil).
 Two doses are given at 6 to 12months.
 If at 15years or more 3 doses are needed.
 The same to be given HIV + regardless of
age.
 Other ways are; fewer partners, condom use
and male circumcision.
B. SECONDARY
 It is screening and treatment of pre-cancer
approach.
 TESTS used are;
 Visual Inspection with Acitic Acid (VIA).
 HPV DNA testing-to be done from the age of
30.
 Papanicolaou(Pap) smear-for post-
menopausal women or those who need follow
up after treatment of cancer.
 Abnormal Pap smear needs colpcoscope
(magnification used to observe cervix in
details)
VIA results
Appearance of the Cervix in Different
Stages of Cervical Cancer
 Two types 1. Ablative 2. Excision
1.ABLATIVE
 It destroys the areas of the cervix with pre-
cancererous and enter transformation zone.
 Can be done by freezing or by burning.
 Examples; cryotherapy, cervical
thermocogulation, cervical electrocoagulation
and Laser ablative.
2.EXCISIONAL TREATMENT
 Large Loop Excision of the Transformation
Zone (LLETZ).
 Cone Knife Conisation (CKC).
 Hysterectomy.
 Diagnosis can be made by tissue biopsy and
histopathological confirmation.
 It requires a multidisplinary approach.
 Diagnosis can be made in a symptomatic
during screening.
 Can also present with symptoms that vary
depending on location and extent of disease.
 Is a clinically staged disease.
 It is based on clinical evaluation.
 These are bimanual vaginal and rectal
examination.
 Imaging studies and specific procedures.
 Most common staging system is International
Federation of Gyenacology and Obstetric
(FIGO)
STAGE DESCRIPTION
0 Pre-invasive carcinoma (carcinoma in situ)
1
1a
1a1
1a2
1b
1b1
Carcinoma confined to cervix (microinvasive
carcinoma)
Invasive cancer identified only microscopically
All gross lesion, even with superficial invasion are
stage 1b cancers
Depth of measured stromal invasion should not be
greater than 5mm and no wider than 7mm
Measured invasion no greater than 3mm in depth and
no wider than 7mm
Measured depth of invasion greater than 3mm in
depth and no wider than 7mm
Clinical lesions confined to the cervix or pre-clinical
lesions greater than 1a
STAGE DESCRIPTION
2
2a
2b
Carcinoma extending beyond the cervix and involving the
vagina (but not the lower 1/3) and /or infiltrating the
parametrium ( but not reaching the pelvic side wall)
Carcinoma has involved the vagina
Carcinoma has infiltrated the parametrium
3
3a
3b
Carcinoma involving the lower third of the vagina and/or
extending to the pelvic side wall (there is no free space
between the tumour and the side wall)
Carcinoma involving the lower third of the vagina
Carcinoma extending to the pelvic wall and /or
hydronephrosis or non-functioning kidney due to
ureteric obstruction caused by tumour
4a
4b
Carcinoma involving the mucosa of the bladder or rectum
and or extending beyond the true pelvis
Spread to distant organs
 EARY-abnormal vaginal discharges, Irregular
vaginal bleeding, post-coital bleeding or
spotting and post-menopausal bleeding or
spotting.
 ADVANCED-frequent and urgent urination,
backache, pelvic pain, wt loss, decreased
urine out put, swelling of lower limbs,
breathlessness (due to anaemia,lung
metastasis and effusion) lickage of urine and
stools through vagina)
 Squamous cell carcinoma 90%
 Adnenocarcinomas 10%
 Mesonephric carcinoma <1%
 It requires surgery, radiotherapy and
chemotherapy.
 However, these have potential side effects.
 These are; infertility, lymphoedema, pain
during sexual intercourse, bowel and urinary
bladder changes and premature menopause.
 Palliative care is important at a certain point.
 National Service Delivery Guidelines for
Cervcal Cancer Prevention and Control.
 April 2019.
 Clinical course on secondary prevention of
cervical cancer based on Visual Inspection
with Acetic Acid and Cryotherapy.
 Reference manual september 2013.

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CERVICAL CANCER presentation for the clinic

  • 2.  Background  Definition  Causes  Risk factors  Prevention  Test/investigation  Treatment  Cervical cancer staging
  • 4.  It is one of the leading causes of cancer related deaths in women worldwide.  Data for 2018 shown an estimated of 567 847 new cases diagnosed.  311 365 women died.  85-90% of these deaths were from low resource settings.  Most die at the age of 35-44.
  • 5.  Highest incidence of cervical cancer occurred in Southern and East Africa.  Malawi has highest burden of the disease.  It has the second highest in the world with age standardised incidence and mortality rates at 72.9 and 49.8 respectively per 100 000 population.  3684 developed cervical cancer in 2018.
  • 6.  2314 die from the disease
  • 7.  Is the biological process in which cells grow without regulation, overwhelming normal cells and function.  When diagnosed late or untreated is almost fatal.  Cervical cancer originates from cervix with an HPV infection.  Can spread to adjacent tissues.
  • 8.  It can also spread to local lymphatic system.  In advanced stage can spread beyond the pelvis.  It has a pre-cancer stage.  It is caused by Human Papilloma Virus (HPV).
  • 9.  Is an easily transimissible DNA virus.  Has more than 150 subtypes.  Different HPV types cause infections in different parts of the body.  Some cause common skin warts and others in genital tract.  Most of the HPV are transient, the body will clear it.
  • 10.  91% of the infections clear up within three years.  It is frequently spread by intercourse and by genital skin to skin contact.  HPV infections are common.  Studies show that by the time that person has had three or more sexual partners they have 50% chance of becoming infected with HPV.
  • 11.  Condom reduces it by 60%.  Some HPV with high risk types are 16 and 18.  70% cervical cancers are caused by these 16 and 18.  HPV 16 is the most oncogenic and cause almost 50%.
  • 12.  Being HIV positive makes 4-6 times more likely to develop into cervical cancer.  Even if client is on ART.  They can progress and die quickly.  Have higher persistent HPV infection.  Have higher prevalence of HPV.  Higher rates of infection with multiple HPV types.
  • 13.  Age (30-50).  Initiation of sexual activity before the age of 20.  Multiple births.  Multiple partners.  Previous abnormal screening test results.  Smoking.
  • 14.  Superimposed infections; simple herpes virus, trichomonias etc.  Immunosuppression.
  • 15. A.PRIMARY  The use of prophylatic vaccines.  Three common vaccines are; 1. Bivalent (HPV 2) protects against HP type 16 and 18. 2. Quadrivalent (HPV4),against 6,11,16,18 3. Nanovalent (HPV9),against 6,11,16,18,31,33,45,52 and 58.
  • 16.  These are effective when given prior to sexual exposure.  In Malawi it recommends girls of 9 to 14 years.  Malawi use HPV4 (Gardasil).  Two doses are given at 6 to 12months.  If at 15years or more 3 doses are needed.
  • 17.  The same to be given HIV + regardless of age.  Other ways are; fewer partners, condom use and male circumcision. B. SECONDARY  It is screening and treatment of pre-cancer approach.  TESTS used are;
  • 18.  Visual Inspection with Acitic Acid (VIA).  HPV DNA testing-to be done from the age of 30.  Papanicolaou(Pap) smear-for post- menopausal women or those who need follow up after treatment of cancer.  Abnormal Pap smear needs colpcoscope (magnification used to observe cervix in details)
  • 20. Appearance of the Cervix in Different Stages of Cervical Cancer
  • 21.  Two types 1. Ablative 2. Excision 1.ABLATIVE  It destroys the areas of the cervix with pre- cancererous and enter transformation zone.  Can be done by freezing or by burning.  Examples; cryotherapy, cervical thermocogulation, cervical electrocoagulation and Laser ablative.
  • 22. 2.EXCISIONAL TREATMENT  Large Loop Excision of the Transformation Zone (LLETZ).  Cone Knife Conisation (CKC).  Hysterectomy.
  • 23.  Diagnosis can be made by tissue biopsy and histopathological confirmation.  It requires a multidisplinary approach.  Diagnosis can be made in a symptomatic during screening.  Can also present with symptoms that vary depending on location and extent of disease.
  • 24.  Is a clinically staged disease.  It is based on clinical evaluation.  These are bimanual vaginal and rectal examination.  Imaging studies and specific procedures.  Most common staging system is International Federation of Gyenacology and Obstetric (FIGO)
  • 25. STAGE DESCRIPTION 0 Pre-invasive carcinoma (carcinoma in situ) 1 1a 1a1 1a2 1b 1b1 Carcinoma confined to cervix (microinvasive carcinoma) Invasive cancer identified only microscopically All gross lesion, even with superficial invasion are stage 1b cancers Depth of measured stromal invasion should not be greater than 5mm and no wider than 7mm Measured invasion no greater than 3mm in depth and no wider than 7mm Measured depth of invasion greater than 3mm in depth and no wider than 7mm Clinical lesions confined to the cervix or pre-clinical lesions greater than 1a
  • 26. STAGE DESCRIPTION 2 2a 2b Carcinoma extending beyond the cervix and involving the vagina (but not the lower 1/3) and /or infiltrating the parametrium ( but not reaching the pelvic side wall) Carcinoma has involved the vagina Carcinoma has infiltrated the parametrium 3 3a 3b Carcinoma involving the lower third of the vagina and/or extending to the pelvic side wall (there is no free space between the tumour and the side wall) Carcinoma involving the lower third of the vagina Carcinoma extending to the pelvic wall and /or hydronephrosis or non-functioning kidney due to ureteric obstruction caused by tumour 4a 4b Carcinoma involving the mucosa of the bladder or rectum and or extending beyond the true pelvis Spread to distant organs
  • 27.  EARY-abnormal vaginal discharges, Irregular vaginal bleeding, post-coital bleeding or spotting and post-menopausal bleeding or spotting.  ADVANCED-frequent and urgent urination, backache, pelvic pain, wt loss, decreased urine out put, swelling of lower limbs, breathlessness (due to anaemia,lung metastasis and effusion) lickage of urine and stools through vagina)
  • 28.  Squamous cell carcinoma 90%  Adnenocarcinomas 10%  Mesonephric carcinoma <1%
  • 29.  It requires surgery, radiotherapy and chemotherapy.  However, these have potential side effects.  These are; infertility, lymphoedema, pain during sexual intercourse, bowel and urinary bladder changes and premature menopause.  Palliative care is important at a certain point.
  • 30.  National Service Delivery Guidelines for Cervcal Cancer Prevention and Control.  April 2019.  Clinical course on secondary prevention of cervical cancer based on Visual Inspection with Acetic Acid and Cryotherapy.  Reference manual september 2013.