Comparison of Different guidelines about Gynecological Cancer Screening protocols applicable to family practice

1. FAMILY PHYSICIAN’S
ROLE IN
GYNECOLOGICAL
CANCER SCREENING
Dr.M. Mataro Hingorjo
R4
Family Medicine AKU
Karachi Sindh.1

2. 2

3. OBJECTIVE
 To determine the most feasible and evidence based
approaches to be applied for Screening of
 Cervical Cancer
 Ovarian Cancer
 Endometrial Cancer
3

4. PERSON #01
 20 year old lady, resident of Layari Karachi, came
to CHC for general checkup, she is married for two
years, P1+0…!
 She belongs to low socioeconomic class
 Which is a major life threatening challenge, that
could be prevented, if addressed properly at this
point in time?
 How would you prevent her?
4

5. CERVICAL
CANCER
5

6. GENERAL IMPRESSION
 Second biggest cancer among women in Pakistan
with about 8,000 reported deaths each year
 Only 1.8% of the women are screened….!
 No national or provincial screening program
 The biggest challenge is the lack of awareness and
access to reliable and affordable screening
resources
6Shahid M, Kazmi SU, Rehman A, Ainuddin J, Furqan S, Nazeer S. Cervical
cancer screening and HPV genotype distribution among
asymptomatic patients of Karachi Pakistan. Pak J Med Sci 2015;31(3):493-
498.

7. RISK FACTORS
BMJ best practice Feb-2015
7
 HPV infection
 Yong age (Teenagers)
 Immunosupression/
HIV
 Early onset of sexual
activity (younger than
18)
 Multiple sexual
partners
 Cigarette smoking
 STDs
 OCP use
 High Parity
 Uncircumcised male
partner
 Malnutrition
 Alcohol use
 Low socio-economic
status
Strong Weak

8. PRESENTATION
 Post-coital Bleeding
 Pelvic pain, Dyspareunia
 Cervical Bleeding
 Cervical mass
 Abnormal vaginal bleeding
 Cervical motion tenderness
 Bleeding to touch cervix
 Mucoid or purulent vaginal discharge
 Bladder, renal, or bowel obstruction
 Bone pain 8
BMJ-bestpractice-feb-2015

9. PREVENTION: HPV VACCINE
 Routine vaccination at age 11 or 12 years (may go
down to 09yrs girls)
 Recommended through age 26 for females and
through age 21 for males not previously vaccinated
 Recommended for immuno-compromised persons
and for men who have sex with men through age
26
 3-dose schedule (0,1-2 and 6 months)
9
CDC-2015

10. RECOMMENDATION FOR
SCREENING…….??????
10

11. PERSON # 02
 A 60-year-old woman presents with 3 months of
progressively worsening abdominal bloating and
early satiety
 Her community Doctor told her that she has
irritable bowel syndrome
 On examination, abdomen is dull to percussion and
distended with minimal tenderness. fluid thrill is
present
 On pelvic examination, the cervix appears normal
,a mass is palpable in the left adnexa
 Most likely diagnosis?
11

12. OVARIAN
CANCER
12

13. GENERAL IMPRESSION
 Middle class disease
 Older population is affected
 Silent killer
 One of the diseases GPs fear missing the most
 Suspicious pelvic mass= Referral for sugery
indicated
 Definitive diagnosis by surgery not biopsy
13
BMJ Best Practice-sept: 2014

14. RISK FACTORS
BMJbestpracticesept2014
14
 BRCA 1, 2 mutation
 Increasing age
 Family History of
ovarian cancer, breast
Caner
 Never used OCPs
 Lynch II syndrome
(HNPCC/ Endometrial
Cancer)
 Nulliparity
 Obesity
Strong Weak

15. PRESENTATION
 Vague symptoms
 Abdominal distension
 Abnormal PV bleeding
 Abdominal discomfort
 Dyspepsia
 Bowel symptoms
 Pelvic Mass
15

16. PREVENTION/SCREENING
 The use of OCPS for a period of 5 years  50%
decrease in the risk
 Risk-reducing salpingo-oophorectomy is currently
the most effective way in high risk group
 No recommended screening in the general
population/ asymptomatic individuals
 Individualized decision:
 TVS and CA-125 measurement every six monthly in
high risk patients
 An annual pelvic examination for first-degree
relatives
16
ACOG 2012, ACS 2013, BMJ2014

17. PERSON # 03
 A 65-year-old woman, HTN,DM,
 c/o
 Post-menopausal vaginal bleeding, 12 years after
menopause
 Never been pregnant
 First-degree relative & a second-degree relative have
had endometrial cancer
 Bleeding is scanty but has persisted for more than 01
month
 Normal Pap smear 6 months previously
 BMI = 41
 Vaginal examination reveals evidence of recent bleeding
Most likely Diagnosis? 17

18. ENDOMETRIAL
CARCINOMA
18

19.  Common malignancy, usually an adenocarcinoma
 Obesity is associated with an increased incidence
and poorer outcome.
 Common presentation is post-menopausal vaginal
bleeding
19
BMJ best practice December 2014
GENERAL IMPRESSION

20. BMJ Best Practice Dec 2014
20
 Obesity
 Age > 50 years
 Endometrial hyperplasia
 Anovulation, early
menarche, late
menopause
 Tamoxifien
 Family History (ovary,
breast, HNPCC)
 Radiotherapy
 Inactivity
 Insulin Resistance
 Nulliparity, Infertility
 White ethnicity
Strong Weak
RISK FACTORS

21. PRESENTATION
 Non-menstrual bleeding or discharge
 Especially post-menopausal bleeding
 Heavy bleeding
 Dysuria
 Pain during intercourse
 Pain and/or mass in pelvic area
 Weight loss
 Back pain
21
BMJBestPracticeDecember2014

22. PREVENTION/SCREENING
 At the time of menopause, all women should be
informed about the
 Risks and symptoms of endometrial cancer
 Strongly encouraged to report any unexpected
bleeding or spotting
 For women with or at high risk for hereditary
non-polyposis colon cancer (HNPCC)
 Annual screening should be offered for endometrial
cancer with endometrial biopsy beginning at age 35
22
TheAmericanCancerSociety-2013

23. PREVENTION/SCREENING
 Prophylactic bilateral salpingo-oophorectomy (BSO) in
high risk group
 Combined OCPs
 Smoking have protective role
 Pre-menopausal women treated with tamoxifen have no
increased risk of endometrial cancer
 There is no evidence to support screening
asymptomatic public
 ACOG recommends screening with pelvic ultrasound
and endometrial sampling in a 6-monthly fashion in high
risk group(HNPCC)
 Family members should also be screened for colorectal
cancer 23
ACOG-2012, ACS-2013, BMJ-Dec-2014, Endometrial Cancer; Am Fam Physician.
2009;80(10):1075-1080, 1087-
1088.

24. PEARLS FOR PATIENTS
 Pay attention to your body and know what is normal
for you
 Make healthy lifestyle choices
 Know your family health history. Share it with your
doctor
 Get the HPV vaccine
24CDC-2015

25. CONCLUSIONS
 Cervical cancer screening is the most successful
program in gynecological cancers
 Ovarian cancer screening is not proven to be cost-
effective yet, may be considered in high risk groups
 Endometrial cancer screening may be consider in
high risk groups
25

26. 26