Cancer of cervix and its management

Cancer of cervix, causes, risk factors, diagnostic tests its management

1. CANCER OF CERVIX AND ITS MANAGEMENT PRESENTED BY KANCHAN MEHRA M.SC NURSING 2 ND YEAR

2. INTRODUCTION Cervical cancer constitute 13% of all cancers in women globally. It is the second most common cancer in women worldwide but the most common cancer in India and other developing countries. Human papilloma virus (HPV) has been identified as the causative agent in most cases. The disease is preventable by screening, early diagnosis and treatment .

3. DEFINITION Cervical cancer is a type of cancer that occurs in the cells of the cervix mostly the lower part of the uterus that connects to the vagina.

4. INCIDENCE 1 in 6000 live births. Most frequently diagnosed cancer in pregnancy Some 80% of cases detected in pregnancy are diagnosed in the first or second trimester. The disease usually squamous cell carcinoma although upto 40% of cases now reported are adenoma carcinomas

5. RISK FACTORS Multiple sexual partners: The greater number of sexual partners — and the greater partner's number of sexual partners — the greater chance of acquiring HPV. Early sexual activity. Sexually transmitted infections (STIs) A weakened immune system

6. Smoking.  Smoking is associated with squamous cell cervical cancer. Exposure to miscarriage prevention drug.  If mother took a drug called diethylstilbestrol (DES) while pregnant in the 1950s, person may have an increased risk of a certain type of cervical cancer called clear cell adenocarcinoma . Prior history of human papilloma virus Family history of cervical cancer

7. PATHOGENESIS OF CERVICAL CANCER BY STAGING Stage I a : Preclinical invasive carcinoma that can be diagnosed only by means of microscopy -Stage Ib : A clinically visible lesion that is confined to the cervix uteri -Stage Ib1 : Primary tumor not greater than 4 cm in diameter. -Stage Ib2 : Primary tumor greater than 4 cm in diameter.

8. Stage IIa : Spread into the upper two thirds of the vagina without parametrial invasion -Stage IIb : Extension into the parametrium but not into the pelvic sidewall

9. Stage IIIa : Extension into lower one third of the vagina, without spread to the pelvic sidewall -Stage IIIb : Extension into the pelvic sidewall and/or invasion of the ureter

10. Stage IVa : Extension of the tumor into the mucosa of the bladder or rectum Stage IVb : Spread of the tumor beyond the true pelvis and/or by metastasis into distant organs

11. SYMPTOMS OF CERVICAL CANCER Early-stage there is no signs or symptoms. Advanced cervical cancer Signs and symptoms include: -Vaginal bleeding after intercourse -Watery, bloody vaginal discharge that may be heavy and have a foul odor -Pelvic pain or pain during intercourse

12. DIAGNOSIS ASYMPTOMATIC CASES - Cytologic screening of all pregnant mothers is a routine during antenatal checkup. - Cases showing dyskaryotic smear are subjected to colposcopic directed biopsy.

13. SYMPTOMATIC CASES: - In cases of bleeding during pregnancy or early months simulating threatened abortion - Or in the later months causes APH, the cervix should be inspected through a speculum at the earliest. If doubt arises, a biopsy from the site of lesion confirms the diagnosis

14. Exfoliative cytology Pap test: The Papanicolaou test is a method of cervical screening used to detect potentially precancerous and cancerous processes in the cervix or colon. Cells scraped from the opening of the cervix are examined under a microscope

15. Pap test ( either slide or liquid-based) with or without typespecific HPV identification, allow early diagnosis in most cases. The reduction in mortality from cervical cancer since the Pap test was introduced in the 1940s is testimony to the success of this screening program. The following are recommendations for cervical cancer screening for women: Annual cervical cytology screening should begin approximately 3 years after initiation of sexual intercourse, but no later than age 21 years. Women younger than 30 years should undergo annual cervical cytology screening.

16. Women who have had 3 consecutive negative annual Pap test results may be screened every 2 to 3 years if they are age 30 or older with no history of CIN 2 or 3, immunosuppression , HIV infection, or diethylstilbestrol (DES) exposure in utero . Annual cervical cytology is another option for women 30 years and older. The use of combination cervical cytology and human papillomavirus (HPV) DNA screening is appropriate for women 30 years and older. Women who receive negative results on both tests should be rescreened no more frequently than every 3 years.

17. Women who have had a total hysterectomy (removal of the uterus and cervix) for reasons other than cervical cancer no longer need to be screened for cervical cancer. Women who have had a supracervical hysterectomy should continue to be screened. Women who have undergone hysterectomy with removal of the cervix and have a history of CIN 2 or CIN 3 should continue to be screened annually until three consecutive negative vaginal cytology test results are achieved.

18. Endocervical scrape cytology by endocervical brush or curet­tage: cytology became the standard screening test for cervical cancer and premalignant cervical lesions with the introduction of the Papanicolaou (Pap) smear

19. Liquid-based cytology: Smeared plastic (not wooden) spatula is placed in a liquid fixative (buffered methanol solution) instead of smearing on a slide. Liquid Based Cytology  (LBC) is a new technique for collecting cytological samples in order to detect cervical cancer.

20. Speculoscopy : Uses a special disposable low-intensity blue-white magnifying device or loupe ( Speculite ) is used to examine the cervix for cancerous or pre-cancerous lesions. 

21. Spectroscopy: Cervical impedance or fluorescence spec­troscopy is specific and sensitive, and provides instant re­sults unlike Pap smears. It is a noninvasive technique which probes the tissue morphology and biochemical composition.

22. Magnoscope has a magnifying lens built in source. It magnifies cells five times and enables visualization of punctuation and mosaics. It is portable and useful in rural areas. Therefore, it is introduced in a few centres in India.

23. Microspectrophotometry is also able to distinguish be­tween benign and malignant cells

24. Colposcopy : Colposcopy is a medical diagnostic procedure to examine an illuminated, magnified view of the cervix as well as the vagina and vulva .

25. Cervicography : It is useful when a colposcopist is not available for spot evaluation. A photograph of the entire external os is taken with a 35-mm camera after application of 5% acetic acid and sent to the colposcopist for selecting areas for biopsy. Because of 50% specificity and sensitivity, this technique is not cost-effective.

26. Cone biopsy Cervical conization refers to an excision of a cone-shaped sample of tissue from the mucous membrane of the cervix. Conization may be used either for diagnostic purposes as part of a biopsy, or for therapeutic purposes to remove pre-cancerous cells . 

27. Tests that may be performed to determine whether cancer has spread include: Cystoscopy or proctoscopy   to check to see if cancer has spread to the urethra or bladder and rectum .

28. Computed tomography scan (CT) , which combines multiple X-rays to provide three-dimensional clarity and show various types of tissue, including blood vessels

29. Magnetic resonance imaging (MRI) , using magnets and radio waves provide three-dimensional body images. It may also be used to determine if a tumor is benign or malignant. Positron emission tomography scan (PET) , called a PET scan. A PET scan is an imaging test that can help reveal how your tissues and organs are functioning. A small amount of radioactive material is necessary to show this activity.

30. EFFECTS OF PREGNANCY ON CARCINOMA CERVIX The malignant process remains unaffected. There may be a rapid spread following vaginal delivery and induced abortion. EFFECTS OF CARCINOMA ON PREGNANCY: There is increased incidence of: (1) Abortion (2) Premature labor

31. (3) Secondary cervical dystocia (4) Injury to the cervix and lower segment leading to traumatic PPH . (5) Uterine sepsis.

32. PREVENTION To reduce the risk of cervical cancer: Administering HPV vaccine Routine Pap test -  Most medical organizations suggest beginning routine Pap tests at age 21 and repeating them every few years.

33. Practice safe sex Limit the habit of smoking

34. MANAGEMENT OF CA CERVIX Different types of management are available for patients with cervical cancer. Some management are standard (the currently used treatment), and some are being tested in clinical trials. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.

35. Standard treatment are used A. Surgery: Surgery (removing the cancer in an operation) is sometimes used to treat cervical cancer. The following surgical procedures may be used:

36. Conization : A procedure to remove a cone-shaped piece of tissue from the cervix and cervical canal. A pathologist views the tissue under a microscope to look for cancer cells. Conization may be used to diagnose or treat a cervical condition. This procedure is also called a cone biopsy.

37. Conization may be done using one of the following procedures: Cold-knife conization : A surgical procedure that uses a scalpel (sharp knife) to remove abnormal tissue or cancer. Loop electrosurgical excision procedure  (LEEP): A surgical procedure that uses electrical current passed through a thin wire loop as a knife to remove abnormal tissue or cancer. Laser surgery: A surgical procedure that uses a laser beam (a narrow beam of intense light) as a knife to make bloodless cuts in tissue or to remove a surface lesion such as a tumor.

38. B) Total hysterectomy: Surgery to remove the uterus, including the cervix. If the uterus and cervix are taken out through the vagina, the operation is called a vaginal hysterectomy. If the uterus and cervix are taken out through a large incision (cut) in the abdomen, the operation is called a total abdominal hysterectomy. If the uterus and cervix are taken out through a small incision in the abdomen using a laparoscope, the operation is called a total laparoscopic hysterectomy .

39. Radical hysterectomy: Surgery to remove the uterus, cervix, part of the vagina, and a wide area of ligaments and tissues around these organs. The ovaries, fallopian tubes, or nearby lymph nodes may also be removed. Radical trachelectomy : Surgery to remove the cervix, nearby tissue and lymph nodes, and the upper part of the vagina. The uterus and ovaries are not removed.

40. Bilateral salpingo-oophorectomy : Surgery to remove both ovaries and both fallopian tubes.

41. Pelvic exenteration : Surgery to remove the lower colon, rectum, and bladder. The cervix, vagina, ovaries, and nearby lymph nodes are also removed. Artificial openings (stoma) are made for urine and stool to flow from the body to a collection bag. Plastic surgery may be needed to make an artificial vagina after this operation.

42. Radiation therapy adjuvant with chemotherapy by staging Radiation theray  is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells.There are two types of radiation therapy:   External radiation therapy  uses a machine outside the body to send radiation toward the cancer. Certain ways of giving radiation therapy can help keep radiation from damaging nearby healthy tissue. Internal radiation therapy  uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.

43. Stage I A simple hysterectomy may be an option if the cancer shows no lymphovascular invasion and the edges of the biopsy have no cancer cells. If the cancer has grown into blood or lymph vessels, patient might need external beam radiation to the pelvis followed by brachytherapy is used.

44. If none of the lymph nodes are found to have cancer, radiation may still be discussed as an option if the tumor is large, if the tumor has grown into blood or lymph vessels, or if the tumor is invading the surrounding connective tissue that supports organs such as the uterus, bladder, vagina (the stroma ). If the cancer has spread to the tissues next to the uterus (called the parametria ) or to any lymph nodes, or if the tissue removed has positive margins, radiation (EBRT) with chemotherapy is usually recommended. The doctor may also advise brachytherapy after the combined chemo and radiation are done.

45. Stage II External beam radiation therapy (EBRT) to the pelvis plus brachytherapy Radical hysterectomy with removal of pelvic lymph nodes - If lymph nodes have cancer cells, radiation may still be an option if the tumor is large.

46. Stages III Treatment options Chemoradiation : The chemo may be cisplatin , carboplatin , or cisplatin plus fluorouracil. The radiation therapy includes both external beam radiation and brachytherapy .

47. Stage IV At this stage, the cancer has spread out of the pelvis to other areas of the body. Stage IV cervical cancer is not usually considered curable. -Treatment options include radiation therapy with or without chemo to try to slow the growth of the cancer or help relieve symptoms .

48. Most standard chemo regimens include – Cisplatin or carboplatin ) along with another drug such as paclitaxel ( Taxol ), gemcitabine ( Gemzar ), or topotecan . The targeted drug bevacizumab ( Avastin ) may be added to chemotherapy  

49. SUMMARY At the end of the Presentation CA Cervix and its management can be helpful for students to know the problem of CA Cervix and its management and understand the definition, incidence, etiology, risk factors, pathogenesis, types, symptoms, diagnosis, effects, prevention, and management of CA Cervix.

50. ABSTRACT G Narayana , Suchitra Jyothi , 2017 was conducted a cross‑sectional study on Knowledge, attitude, and practice toward cervical cancer among women attending Obstetrics and Gynecology Department in South India. 403 women were included as sample by convenient sampling method and using interview, pre-validated Knowledge, attitude, and practice questionnaire on cervical cancer. The result showed that most of (74.6%) the respondents had heard about cervical cancer and majority of them are heard from media (41.6%) and friends (20.5%). Most women knew symptoms (64.2%), risk factors (62.7%), screening methods (76.9%), and preventive measures (61.7%) for cervical cancer. More than half of the women (252; 62.5%) having positive attitude toward screening.Thus the study concluded that although women are having good knowledge, positive attitude toward cervical cancer screening and prevention still there is a gap to transform it into practice. There is a need for more educational programs to connect identified knowledge slits and uplift of regular practice of cervical cancer screening.

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