Cervical Cancer Can we prevent it?

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Cervical Cancer Can we prevent it?

• Dr Paul Byrne MD FRCOG FRCPI
• Department of Obstetrics Gynaecology
• Rotunda Hospital Beaumont Hospital

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Overview

• Cervical cancer- what is it?
• Epidemiology
• Natural history of cervical neoplasia
• Prevention of cervical cancer
• Cervical Pap smears
• Abnormal smears
• Treatment of cervical cancer
• Vaccination

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Epidemiology

• Commonest cancer in women in developing countries
• The second most common cancer in women worldwide
• The eight most common cancer diagnosed in women
  in Ireland

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Ranking of the most commonly diagnosed invasive
cancers in women 2007-2009
Organ Rank
Breast 1 32.3
Colorectal 2 11.4
Lung 3 9.5
Melanoma 4 4.7
Corpus Uteri 5 4.3
Lymphoma 6 4.0
Ovary 7 3.8
Cervix 8 3.5
Pancreas 9 2.6
Stomach 10 2.2
National Cancer Registry (Ireland)
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Average Annual Incidence of cancer diagnosis
2007-2009
Organ Number of cases of all cancers
Breast 2673 32.3
Cervix 287 3.5
National Cancer Registry (Ireland)
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Annual Cancer Deaths 2006
Organ Deaths (female) Mortality Rate Cancer Deaths
Breast (1st) 678 30.4 17.5
Lung (2nd) Colorectal (3rd) Ovary (10th) 659 419 275 28.6 16.3 12.4 17.1 10.8 7.1
Cervix (19th) 83 4.2 2.1

National Cancer Registry (Ireland)
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Transformation Zone

• Squamous epithelium
• Columnar epithelium
• Squamo-columnar junction

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Cervical Transformation Zone

• Columnar Epithelium ? (metaplasia) ? Squamous
  epithelium

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Natural History of Cervical Neoplasia

• Columnar Epithelium ?(metaplasia) ? Squamous
  epithelium

Oncogenic Stimulus
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Natural History of Cervical Neoplasia

• Columnar Epithelium ?(metaplasia) ? Squamous
  epithelium

Oncogenic Stimulus
CIN
Cancer
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Natural History of Cervical Neoplasia

• Columnar Epithelium ?(metaplasia) ? Squamous
  epithelium

HPV
Nicotine
Oncogenic Stimulus
CIN
Cancer
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Natural History of Cervical Neoplasia

• NORMAL ?? CIN1 ??CIN 2 ??CIN 3 ?INVASION

HPV
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Natural History of Cervical Neoplasia

• NORMAL ?? CIN1 ??CIN 2 ??CIN 3 ?INVASION

NICOTINE
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Cervical Intraepithelial Neoplasia (CIN)
SIL Squamous Intraepithilial lesion
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Cervical Neoplasia - A sexually transmitted
disease

• Cervical cancer
• Rarely seen in women who have never had sexual
  intercourse
• Risk of developing cervical cancer is related to
• Early age at first intercourse
• Number of partners
• HPV is sexually transmitted
• Cervical neoplasia occurs when the cervical
  transformation zone is exposed to HPV

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Human Papillomavirus (HPV)

• A double stranded DNA virus that infects squamous
  epithelia where it causes warts and tumours
• 100 different types of HPV
• HPV types 6 and 11 cause approximately 90 of
  genital warts
• Genital warts are highly contagious - two-thirds
  of people who have sexual contact with an
  infected partner will develop warts
• HPV types 16 and 18 cause approximately 70 of
  cervical cancers

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Prevention of deaths from cervical cancer
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Screening for Cervical Neoplasia

• Cancer of the cervix is unusual compared to other
  cancers
• Prolonged precancerous phase
• The cervix is accessible
• Precancerous phase is detectable
• (Pap smear)
• Proven success of population screening

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• Introduction of a national cervical screening in
  Ireland
• - September 2008

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Based on a target uptake of 80 per cent, a
successful national, quality assured cervical
screening programme has the potential to
significantly reduce mortality rates in the
screened population by as much as 80 per cent by
the end of the second full screening round in
2014
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Colposcopy

• Low power magnification of the cervix
• Assess the transformation zone
• Detect CIN
• Treat CIN

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Abnormal Transformation zone CIN3
Normal transformation zone
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LLETZ procedure

• Large Loop Excision of the Transformation Zone
• Local anaesthesia
• Treatment of CIN 2 3, and persistent CIN1
• See and Treat
• Follow up with annual smears for 10 years

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Colposcopy and LLETZ Procedure
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Treatment of Cervical Cancer

• Stage 1b 2A
• Radical Hysterectomy
• Also known as Wertheim Hysterectomy
• Total abdominal hysterectomy, parametria, upper
  third of vagina, pelvic lymph nodes.
• Ovaries need not be removed, especially in
  younger women.
• Higher morbidity than simple hysterectomy
• Advanced stages
• Radiotherapy /- Chemotherapy

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Survival
Stage 5-year survival
Ia1 90
Ia2-Ib2 85
II 60
III 40
IV 15
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Schools HPV Vaccination Programme in Ireland
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Exam Question
Cervical Cancer- a preventable disease. Discuss.