Tutorial 16: Cervical Cancer Flashcards
(49 cards)
1
Q
What are some facts surrounding the history of cervical screening in New Zealand?
A
- National Cervical Screening Program was launched in New Zealand in 1990
- –> Since then the NCSP has resulted in a 40% reduction in the incidence of cervical cancer
- Breast Screen Aotearoa commenced their screening program in 1998
- In the first two years 1184 cancers have been detected through the program
- Testing for high risk HPV subtypes was introduced in New Zealand in October 2009
2
Q
What are the WHO principles for developing a Screeing Prgram in terms of the condition?
A
- Should be an important health problem
- Should have a recognizable latent or early symptomatic stage
- The natural history of the disease, from latent phase to declared disease, should be adequately understood
3
Q
What are the WHO principles for developing a Screening Program in terms of the test and treatment?
A
Test:
- There should be a suitable test or examination
- The test should be acceptable to the population
Treatment: There should be accepted treatment for patients with recognized disease
4
Q
What are the WHO principles for developing a Screening Program in terms of the logistics of the program itself?
A
- Facilities for diagnosis and treatment should be available
- There should be an agreed policy on whom to treat as patients
- The cost of case finding (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole
- Case finding should be a continuing process and not a “once for all” activity
5
Q
What is the epidemiology of cervical cancer worldwide?
A
- Worldwide, cervical cancer is the second-leading cause of cancer death in women
- Globally, each year around 500,000 women are diagnosed and nearly 300,000 die
6
Q
What is the epidemiology of cervical cancer in New Zealand?
A
- In New Zealand, approximately 160 women develop cervical cancer each year and about 60 women die from it.
- Regular screening reduces the chances of getting cervical cancer. Without it, one in 40 women would develop cervical cancer.
- The death rate from cervical cancer for Maori women is four times as high as non-Maori women. The reason is not known however it is believed this is due to reduced compliance by Maori women with cervical screening.
- Cervical cancer has the youngest age of first diagnosis compared to other cancers. It often occurs in women in their 40s and 50s, when many are still raising children and contributing to their families’ livelihoods and security.
- Some groups of women have higher rates of cervical cancer. These include:
- Women over 40
- Māori and Pacific women
7
Q
Which groups of woman in the NZ population have higher rates of cervical cancer?
A
- Woman >40yo
- Maori women
- Pacifica women
8
Q
What facts surrounding the benefits and limitations of cervical and breast screening should you include when counselling woman on available screening?
A
Cervical screening is useful because cervical cancer is preceded by cellular changes which can be detected by taking a sample from the cervix.
- Treating the abnormalities leads to a reduction in cervical cancer.
With screening the chances of getting cervical cancer decreases from 1/90 women without screening –> to 1/570 women with screening.
Likewise the chances of dying from cervical cancer decreases to 1/1280 from 1/200 women without screening.
9
Q
Who is included in the Cervical Screening Programme?
A
- Women 20-69y: Every 3 years
Which Woman are at increased risk for cervical cancer:
- 40+ women who’ve never had smear
- Those with no smear for 5 years
Women who don’t need smears are those who have:
- Had total hysterectomy with normal cervical cytology prev.
- Never had sexual intercourse
10
Q
What is Cervical Intraepithelial Neoplasia?
A
- CIN = The presence of atypical cells in squamous epithelium of cervix.
- CIN is a Premalignant condition.
- Atypical cells show enlarged nuclei, increased nuclear/cytoplasmic ratio, increased mitoses.
- Severity of CIN graded according to depth of atypical cells
11
Q
What are the three main features of atypical cells in CIN/the squamous epithelium of the cervix?
A
- Enlarged nuclei
- Increased nuclear:cytoplasmic ratio
- increased mitosis
12
Q
What is the grading/severity used for CIN/cervical intrapeithelial neoplasia?
A
Severity of CIN graded by depth of atypical cells
CIN1 = atypical cells only in the lower 1/3 of epithelium
CIN2 = atypical cells in the lower 2/3 of epithelium
CIN3 = atypical cells throughout the full thickness of epithelium.
- CIN3 was previously know as CIS (carinoma in situ)
13
Q
What are the two classification groups whicha re used when grading cervical intraepithelial neoplasia?
A
-
Low Grade Squamous Intraepithelial lesions (LSIL)
- CIN1
- ASCUS (abnormal cells of undetermined significance)
-
High Grade Squamous Intraepithelial Lesions (HSIL)
- CIN 2/3
14
Q
What does ASCUS stand for?
A
ASCUS = Abnormal Squamous Cells of Undetermined Significance
15
Q
What is the role of HPV (human papilloma virus) to cervical cancer?
A
HPV is sexually transmitted and cervical screening is only necessary for women who are sexually active.
- HPV is acquired soon after the initiation of sex
- But most HPV is cleared, especially in younger women – about 70% of young women clear HPV in 12 months.
- Types 6 and 11 cause genital warts
- Types 16 and 18 are responsible for around 70% of cervical cancers
Gardasil is a quadrivalent vaccine and is available on the NZ immunization schedule.
-
Untreated, approximately 30% of women with HSIL (CIN2/3) would progress to invasive cervical cancer over 10 years.
- LSIL (CIN1) carries only a small risk of malignant progression. It may progress to CIN2/3 but it commonly resolves without treatment.
- LSIL in young women is usually watched initially – yearly smears for the first 3 years.
The presence and persistence of LSIL into the thirties suggests that the immune system has failed to clear the HPV and the follow up in this age group is different.
16
Q
What particular subtypes of HPV are of importance regarding cervical cancer?
A
- 6 + 11 = genital warts
- 16 + 18 = 70% of cervical cancers
The high-risk types include:
- HPV 16, HPV 18,
- HPV 31, HPV 33, and HPV 45,
17
Q
What is the Transformation Zone and what is its relevance to cervical cancer?
A
- Before puberty the:
- ectocervix is covered by stratified squamous epithelium
- endocervical canal and crypts are covered by columnar epithelium
- The original squamocolumnar junction is therefore near the external cervical os
- During puberty the tissues in the lower part of the cervical canal are everted and the glandular epithelium now comes to lie on the vaginal portion of the cervix
- This results in “Ectropion”: the protuberant endocervical mucosa surrounding the external os
- It has a granular, red and inflamed appearance on examination
18
Q
What is the management of a patient with LSIL?
A
- 20-29yo: Repeat smear 1 year
- 20-69: 1 abnormal smear in last 5 years –> colposcopy
-
30+: HPV Test
- +ve HPV test = colposcopy
- -ve HPV test = Repeat in 1 year, then return to normal screening program
19
Q
What type of language and specific points should be covered when explaining smears?
A
- Non discriminative, empathetic and Understanding
- Specific points to explain
- Abnormal cells do not mean cancer
- MUST ATTEND SPECIALIST APPOINTMENT DUE TO HIGH RISK
20
Q
What are some misconceptions about abnormal smears?
A
- Abnormal smears mean cervical cancer.
- Smears only detect pre-cancerous cells (abnormal cells).
- Abnormal smears are related to STD
- Might cause relationship disruption (HPV dx doesnt mean cheating)
- Must explain that HPV can remain dormant for many years, therefore may have picked it up from previous partners.
21
Q
When is a colposcopy referral nescessary for cervical cancer?
A
- When smear results show HSIL (CIN2/3).
- Colposcopy: The cervix is examined under magnification and acetic acid and/or iodie stain is applied with biopsy of abnormal looking areas. These may need excision by LLETZ (large loop excision of the transformation zone) or by laser cone
- What is it: Colposcopy is a magnified visual examination of the cervix, vagina and sometimes the outer lips or vulvar area. By using a colposcope, which is a special type of microscope, a healthcare professional can check for problems on the cervix and vagina that can’t be seen during a regular exam. If abnormalities are noticed through the colposcope, a tissue sample (biopsy) can be taken to find the cause.
- Why: The most common reason for a colposcopy is an abnormal cervical screening test (smear test). A colposcopy may be also required to investigate unexplained vaginal bleeding, to diagnose bacterial or viral infections, or to diagnose conditions such as genital warts or polyps (non-cancerous growths).
- Referral: referring doctor will provide relevant smear and swab results with the referral. It is our aim to offer you an appointment as soon as your referral has been triaged and prioritised by our doctors.
- Process: A colposcopy generally takes 10 to 20 minutes. Follow-up is provided by a National Women’s Health gynaecology specialist or referred back to your primary care doctor.
- Free of cost
- *HPV testing may also be used to help determine management
22
Q
What are some alternatives uses of colpsocopy, apart from for an abnormal cervical smear test?
A
- Abnormal smear
- unexplained vaginal bleeding
- diagnose bacterial or viral infections
- genital warts or polyps (non-cancerous growths)
23
Q
What is the difference between a LLETZ, LEEP and a Cone Biopsy?
A
Large Loop Excision of the Transformation Zone (LLETZ)
- Electrical wire loop to remove abnormal cervical cells under local anaesthetic by colposcopic vision (magnified).
Cone biopsy
- Removes a larger cone shaped section of the cervix containing abnormal cells. This is usually done under General Anaesthesia.
Tissues obtained from both techniques are then sent to the lab.
24
Q
What are some risk factors for cervical cancer?
A
- HPV infection
- Smoking
- Immunosuppression
- Chlamydia infection
- Diet
- Oral contraceptives
- Multiple full term pregnancies
- Young age at first full-term pregnancy
- Poverty
- Family history of cervical cancer
- DBES
- Intrauterine device use
25
Why is HPV infection a risk factor for cervical cancer?
* HPV is a group of more than 150 related viruses, some of which cause a type of growth called a **papilloma;** more commonly known as **warts**.
* HPV can be passed from one person to another during **skin-to-skin contac**t. One way HPV is spread is through sex, including *vaginal* and *anal* intercourse and even *oral* sex.
* The high-risk types include:
* HPV **16**, HPV **18**,
* HPV **31**, HPV **33**, and HPV **45**,
* There _might be no visible signs of infection_ with a high-risk HPV _until pre-cancerous changes or cancer develops._
26
Why is smoking a risk factor for cervical cancer?
* Women who smoke are about **twice** as likely as non-smokers to get cervical cancer
* Researchers believe that these substances _damage the DNA of cervix cells_ and may contribute to the development of cervical cancer
* Smoking also makes the _immune system less effective_ in fighting HPV infections.
27
Why is immunosuppression a risk factor for cervical cancer?
* Human immunodeficiency virus (**HIV**), the virus that causes AIDS, damages the immune system and puts women at higher risk for HPV infections. This might explain why women with AIDS have an i_ncreased risk for cervical cancer_.
* Another group of women at risk of cervical cancer are women receiving **drugs to suppress their immune response**, such as those being _treated for an autoimmune disease_ or those who have had an organ transplant.
28
Why is a chlamydia infection a risk factor for cervical cancer?
* Chlamydia is a relatively common kind of bacteria that can infect the reproductive system. It is spread by sexual contact.
* Chlamydia infection can cause **pelvic inflammation, leading to infertility**. Some studies have seen a higher risk of cervical cancer in women whose blood test results _show evidence of past or current chlamydia infection._
29
Why is a poor diet a risk factor for cervical cancer?
* Women whose diets _don’t include enough fruits and vegetables_ may be at increased risk for cervical cancer.
* **Overweight** women are more likely to develop **adenocarcinoma** of the cervix
30
Why are oral contraceptives a risk factor for cervical cancer?
* Research suggests that the risk of cervical cancer goes up the longer a woman takes OCs,
* but **the risk goes back down again after the OCs are stopped**
31
Why are multiple full term pregnancies a risk factor for cervical cancer?
* Women who have had 3 or more full-term pregnancies have an increased risk of developing cervical cancer. No one really knows why this is true.
* One theory is that these women had to have had **unprotected intercourse** to get pregnant, so they may have had **more exposure to HPV**
32
Why is a young age at the first full-term pregnancy a risk factor for cervical cancer?
* Women who were _younger than 17 years_ when they had their first full- term pregnancy are almost **2 times more likely** to get cervical cancer later in life than women who waited to get pregnant until they were 25 years or older.
33
Why is poverty a risk factor for cervical cancer?
* Poverty is also a risk factor for cervical cancer.
* Many low-income women **do not have ready access to adequate health care services**, including Pap tests.
* This means they may _not get screened or treated_ for cervical _pre-cancers_.
34
Why is a family history of cervical cancer a risk factor for cervical cancer?
* Cervical cancer may run in some families. If your mother or sister had cervical cancer, your chances of developing the disease are **2 to 3 times higher** than if no one in the family has it (first degree relative).
35
Why is DBES use a risk factor for cervical cancer?
* Diethylstilbestrol (DES) is a **synthetic form** of the female hormone **estrogen** It was prescribed to pregnant women between 1940 and 1971 to **prevent miscarriage, premature labor, and related complications of pregnancy.**
* In 1971, researchers linked prenatal (before birth) DES exposure to a type of cancer of the cervix and vagina called **clear cell adenocarcinoma** in a small group of women.
* The daughters of women who used DES while pregnant—commonly called DES daughters—have about **40 times** the risk of developing clear cell adenocarcinoma of the lower genital tract than unexposed women. However, this type of cancer is _still rare_; approximately 1 in 1,000 DES daughters develops it.
36
Why is Intrauterine device **IUD** use a **protective** factor for cervical cancer?
* A recent study found that women who had ever used an intrauterine device (IUD) had a lower risk of cervical cancer.
* The effect on risk was seen even in women who had an **IUD for less than a year**, and the **protective effect remained after the IUDs were removed.**
37
What is the typical presentation of a woman with cervical cancer?
* PV bleeding: Usually Post Coital
* Vaginal discomfort
* Malodourous discharge
* Dysuria
* Rarely vaginal mass
* Advanced disease:
* Leg pain, back pain, bone fractures
* Leakage of urine or faeces from vagina (Vesicovaginal and Rectovaginal Fistula)
* Lymphedema, haematuria and rectal bleeding (from local invasion of ureters and rectum respectively)
* Constitutional Symptoms: Weight loss, Night sweats, fevers, fatigue, malaise, loss of appetite etc.
38
What investigations would you order if a patient had an abnormal smear?
1. Refer for colposcopy immediately: Biopsy areas of dysplasia and send for histological analysis
2. If **CIN1 or normal:** _two smears at yearly_ intervals indicated. Return to colposcopy if abnormal smears.
3. If **CIN2/3**, _treatment_. (Treatment chosen depends on the site of the lesion, size, and (to some extent) patient preference).
1. **LLETZ** (large loop excision of the transformation zone using a diathermy loop), **laser vaporisation, cryotherapy, local excision (cone biopsy)** and (rarely) _hysterectomy_ are all effective treatments.
* Advise woman that all types of treatment are associated with a small increase in obstetric risk (SGA, premature delivery, rupture of the membranes).
4. Follow-up:
1. **Colposcopy and cytology at 6-12 month**s. Treat if necessary
2. **Cytology and hrHPV testing at 12 and 24 months** post-treatment.
1. If both negative on both occasions, may return to 3 yearly screening.
2. If hrHPV positive or cytology ASC- H (atypical squamous cells, cannot exclude HSIL) or worse, refer to colposcopy.
39
What should you advise all woman who recieve treatment for CIN 2/3?
Advise woman that all types of treatment are associated with a **small increase in obstetric risk i.e.:**
* SGA
* premature delivery
* rupture of the membranes
Also:
* All these treatment have a profound effect on **reproductive** and **sexual function.**
* HRT and counselling may be required.
40
What are some key differences between surgical treatments for cervical cancer vs other gynaecological cancers?
* Surgery is **common** for small cancers found only within the cervix. The extent of the cancer in the cervix will determine the type of surgery needed.
* **Cone** biopsy – some very early cervical cancers may be treated with cone biopsy.
* **Hysterectomy** – this is the surgical removal of the uterus and cervix.
* Types of hysterectomy:
* **Total** hysterectomy – removal of the **uterus and cervix.**
* **Radical** hysterectomy – removal of the uterus and about **two centimetres of upper vagina** and **tissues around the cervix.**
* When you have either type of hysterectomy, you may also have a:
* _BOS Bilateral salpingo oophorectomy_ – removal of ovaries and fallopian tubes.
* _Pelvic lymphadenectomy_ – removal of lymph nodes in the pelvis.
41
What are two types of hysterectomies?
1. **Total** hysterectomy – removal of the **uterus and cervix.**
2. **Radical** hysterectomy – removal of the _uterus_ and about **2cm upper vagina** and **tissues around the cervix.**
42
What are some key differences between radiotherapy for cervical cancer vs other gynaecological cancers?
* Radiotherapy is used for more **advanced** lesion
* Radiotherapy is usually given if:
* the patient is **not well enough for surgery** OR
* if the cancer has **spread into the surrounding tissue**.
* Can be given _externally_ or _internally (brachytherapy)_
* Side effects: Tiredness, loss of appetite, diarrhoea, pain when passing urine and skin problems. May cause infertility problems and symptoms of menopause
43
What types of radiotherapy are available for cervical cancer?
External
Internal (Brachytherapy)
44
What are some side effects of radiotherapy?
* Tiredness
* loss of appetite
* diarrhoea
* pain when passing urine
* skin problems
* infertility problems
* cause symptoms of menopause
45
What are some key differences between chemotherapy for cervical cancer vs other gynaecological cancers?
* Chemotherapy is **usually combined with radiation** treatment to make the treatment more effective.
* Chemotherapy may also be used on its **own for advanced cervical cancer.**
****
* _Recurrent_ cancer has **poor response to chemotherapy.**
* Side effects: feeling sick (nausea), vomiting, feeling off-colour and tired and hair loss
46
When is chemotherapy less effective for cervical cancer?
recurrent cervical cancer has a poor response to chemotherapy
47
What are some side effects of chemotherapy?
* feeling sick (nausea) & vomiting,
* feeling off-colour
* fatigue
* hair loss
48
What is the role of combined radiotherapy and chemotherapy in cervical cancer treatment?
* A combination of radiation treatment and chemotherapy is being used increasingly to treat cervical cancer.
* Combined radiation treatment and chemotherapy causes **more severe side effects** than radiation treatment alone
49
What should you make all woman aware of when receiving treatment for cervical cancer?
All these treatment have a **profound effect on reproductive** and **sexual function**.
* **HRT** and **counselling** may be required.
