Gynaecological Cancers

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Gynaecological Cancers

• Malcolm Padwick MD FRCOG

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Cervical Cancer
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Cervical Cancer

• 1992 national targets set for year 2000
• 1. Reduce mortality by 20
• 2. Achieve 80 smear uptake
• 1991 targets had already been achieved
• Mortality rate had been falling since 1950 at a
  rate of 1 -2 per annum
• Now 2.3 per 100000

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At risk groups

• Young (immature TZ)
• Early age of first sexual intercourse
• Multiple partners
• Smoking
• Type of contraception
• Screening history

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Screening intervals (2004)
Age Group (years) Frequency of Screening
25 First invitation
25 - 49 3 yearly
50 - 64 5 yearly
65 No screen since age 50 yrs or recent abnormal smear
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HPV

• HPV subtyping will become available
• Concentrate screening on genuinely at risk women
• Allow an increase in the screening interval
• Avoid unnecessary intervention

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Referral to Colposcopy

• 3 inadequate smears
• 2 mildly dyskariotic / borderline smears
• First moderately or severely dyskariotic smear
• Glandular abnormalities
• Suspicion of malignancy

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Colposcopy visit

• Information sheets with appointment
• Separate clinic waiting area
• Changing and washing facilities
• Separate consultation area
• Comply with NHSCSP appointment waiting times
• Comply with NHSCSP waiting times for results

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Scale of problem

• Watford referrals 1995
• 228 new patients

• Watford referrals 2003
• 618 new patients

Therefore a follow-up policy change introduced
(NHS)
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Colposcopy

• Assess
• Biopsy and act on results when available
• See and treat

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After effects

• 3 weeks of diminishing blood stained discharge
• Risk of secondary infection at 1 week
• Next period often heavy and painful
• Overall post operative pain is minimal
• gt98 have a clear or better smear result at 6
  months

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Cervical cancer

• From colposcopy
• General clinic with abnormal bleeding
• Acute admission with symptoms of advanced disease

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Staging

• EUA and cystoscopy
• Pelvic MRI
• Abdominal and chest CT

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Treatment

• Surgery
• Cone biopsy
• Radical trachylectomy
• Radical hysterectomy
• Neoadjuvant chemotherapy combined with radical
  surgery
• exenteration

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Treatment

• Chemo-radiation as a primary treatment
• Radiotherapy as post operative treatment for poor
  prognostic disease
• Chemotherapy or radiotherapy for palliation

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consequences

• Surgery
• Acute complications
• Fistula
• Bladder dysfunction
• Body image
• General improvement with time.

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consequences

• Chemoradiation
• Alopecia
• Radiation burns
• Vaginal stenosis and inflammation
• Cystitis and colitis
• Fistula bowel and bladder
• Side effects tend to get worse with time.

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The future

• Improved prevention
• Less invasive treatment for pre-cancer
• vaccination

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outcome

• Stage
• I
• II
• III
• IV

• 5 year survival
• 80
• 60
• 20
• 5

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Malcolm Padwick MD FRCOG

• Gynaecologist
• West Herts NHS Trust

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Ovarian Cancer
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General impression

• Middle class disease
• Effects older population
• Silent killer
• One of the diseases GPs fear missing the most

Mortality 12 per 100000
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At risk groups

• Post menopausal
• Nulliparous
• Family history (including breast cancer)
• Contraceptive usage
• Endometriosis
• Environmental

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Screening

• Genetic - BRCA 1 and 2 mutations
• USS and CA125 ?????
• Prophylactic oopherectomy after 40 years
• /- HRT
• General population
• USS and CA125 ?????
• Research projects only

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presentation

• Abdominal distension
• Abnormal PV bleeding
• Abdominal discomfort
• Dyspepsia
• Bowel symptoms
• From physicians and general surgeons

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Investigations

• CA125
• USS
• laparoscopy
• CT
• MRI

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Management

• MDT
• Surgery /- chemotherapy
• Staging and randomization into interval debulking
  study
• Interval debulking
• Pregnancy associated mass

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Follow-up

• CA125
• CT
• Relapse chemotherapy
• Relapse surgery

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Outcome

• Stage
• I
• II
• III
• IV

• 5 Year survival
• 90
• 70
• 25
• 5

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Future

• ?

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Endometrial Cancer

• Malcolm Padwick

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Endometrial Cancer

• 65 of all cancers in women
• postmenopausal
• obese (hypertensive, diabetic)
• HRT
• tamoxifen

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Symptoms

• PMB
• IMB
• PCB
• Pap smear
• Pain
• Weight loss, bowel and bladder changes
• Abnormal bleeding on HRT

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Managment

• Refer to the rapid access clinic
• Use cancer pro forma

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Investigations

• Pelvic USS
• If endometrial signal gt 4mm for endometrial
  biopsy -- either pippelle or hysteroscopy and
  currettage
• High risk symptoms go straight to H C