International women's day

1. DR GEETANJALI S VERMA CSI RAINY MULTISPECIALITY HOSPITAL

2. “For most of history, Anonymous was a woman.”  Virginia Wool

3. HISTORY OF WOMEN’S DAY This was first celebrated on 19 th March 1911 but is now celebrated every 8 th March. Women join to celebrate the date that represents equality, justice,peace and development. International Women’s Day is rooted in the struggle of women seeking to participate on an equal footing with men.

4. Mary Wollstonecraft She was the first woman to demand votes for women. 1792 her book entitled Vindication of the Rights of Women argued for equal education, and for single women to earn their own living. She fought hard for women even though she had much personal unhappiness. Unfortunately this led her to being criticised and her ideas dismissed by many, including women.

5. Rich Victorian Women

6. Although rich women had an easier life they had a common denominator with poor women: they had no legal status. A married woman’s earnings belonged to her husband. Her property and goods all belonged to her husband. A woman could not vote. A woman could no go to university. She could not get a divorce on grounds of adultery (although her husband could). It was almost impossible to get a divorce at all until 1857. The law said that children had one parent, a father. He decided on their education and if a couple separated he could refuse to let the mother even see them.

7. Caroline Norton Caroline had a brutal husband who accused her of adultery. She was unable to defend herself in court as she had no legal status. Her husband took her children and also all her earnings (she was a writer). Caroline wrote on the Custody of Infants and had some effect: 1839 the bill said children under seven could stay with their mother if the courts agreed she had a good character. Caroline also wrote on making divorce laws fairer. Therefore she helped legal equality for women.

8. Barbara Bodichon Barbara supported the Married Women’s Property Bill in 1856. This resulted in an Acts of Parliament allowing women living with husbands or those separated to keep their own earnings By 1882 women could own their own property and give it to whoever she wished.

9. Voting: arguments used against women Women are incapable of rational thought. Women are physically too frail and weak to take on the burden of decision. Women are incapacitated by frequent childbearing to bother to vote. Men will make the right decisions for them. If women have the vote they will upset the current order and cause unpleasant changes.

10. “In politics, If you want anything said, ask a man. If you want anything done, ask a woman.”    Margaret Thatcher

11. FROM NO VOTING RIGHTS TO RULING

12. “You educate a man; you educate a man. You educate a woman; you educate a generation.”    Brigham Young

13. Florence Nightingale Worked as a nurse in the Crimean and drastically reduced the death rate. Introduced nursing as a profession and started a nursing school. Involved in improving military hospitals Used health statistics effectively Hospital planning Community nursing.

14. Mary Seacole A nurse who used herbs and natural remedies. Self funded to go to the Crimean and nurse soldiers on the battlefield - a true ‘field’ nurse attending the wounded on the front line Sometimes called the ‘forgotten Nightingale’.

15. Women in WWI and WWII Munitions factory

16. Mother Theresa A Catholic nun who devoted her life to caring for the poor and sick in Calcutta, India. She was revered as a living saint for her work and won the Nobel Peace Prize.

17. Marie Curie She won two Nobel prizes for her work in science. Discovered radium with her husband Pierre In WWI she equipped ambulances with mobile X ray units and drove them to the front lines Her work helped X rays in surgery Her research led to treatment of cancer by radiation.

18. CANCERS IN WOMEN

19. BREAST CANCER

20. EPIDEMIOLOGY Incidence : Breast cancer is the most common lethal neoplasm in women. The incidence varies among different populations 1 out of 8 women will have BC in her life--time. ~ 25 percent of women with cancer have BC. The incidence of male breast canceris about 1% of all breast cancer cases occur in men.

21. US incidence Affects 1 in 8 women living to 85yrs age Total cases 2008 : 211,000 Total deaths : 40,500 (1/6 th of female deaths) Ethnic incidence Causacians – hispanic - asians – african american Stage at presentation localised 58% (node -) Regional 32% (node + / stage 3)

22. Age Incidence by age 30 1 in 2,525 by age 40 1 in 217 by age 50 1 in 50 by age 60 1 in 24 by age 70 1 in 14 by age 80 1 in 10

23. RISK FACTORS Highly elevated RF (relative at 4 times risk) Female Age>50yrs Personal history of prior breast cancer Family history Atypical proliferative benign breast disease esp with family history Moderately elevated RF (relative at 2 - 4 times risk) Any 1 st degree relative with breast cancer Upper SES Prolonged interrupted menses Post menopausal obesity h/o cancer ovary or endometrium proliferative benign breast with no atypia Slightly elevated RF (relative at 1-2 times risk) Moderate alcohol intake Menarche <12yrs old HRT/ OCP/ Diet

24. PATHOLOGY Non – Invasive Lobular (LCIS) Ductal (DCIS) Invasive Low Risk * Standard (high) Risk Pure Tubular Ductal Pure Mucinous /Colloid Lobular Pure Papillary Medullary ** Pure Medullary ? Mixed Squamous * Requires careful pathology review ** atypical and mixed

25. CLINICAL PRESENTATION The majority of carcinoma in situ, T1, or T2: Painless or slightly tender breast mass or have an abnormal screening mammogram. Patients with more advanced tumors : breast tenderness, skin changes, bloody nipple discharge, or occasionally change in the shape and size of the breast. Rarely patients may present with axillary lymphadenopathy (which occasionally may be painful) or distant metastasis.

26. SCREENING MAMMOGRAPHY Established Guidelines Annual 2 view study in women 50 years of age and older Meta - analysis 13 randomized trials 26% reduction in breast cancer

27. Screening Patient without physical finding or symptoms MLO - mediolateral oblique (side) CC - craniocaudal (above) Diagnostic new symptoms - lump, thickening, skin change additional imaging including magnification additional evaluation including US

28. INTERPRETATION BIRADS - Breast Imaging Reporting and Data System Category Assessment Recommendations Incomplete Additional views 1 Negative Routine - 12 months 2 Benign Routine - 12 months 3 Probable Benign F/U short term -6mos. 4 Suspicious Biopsy considered 5 Cancer suggested Appropriate action

29. DIAGNOSIS Fine Needle Aspiration Ultrasound Guided Core Biopsy Excisional or Incisional Biopsy

30. TREATMENT NON INVASIVE DUCTAL 1) Complete Excision Alone 2) Complete Excision + RT 3) Mastectomy Margins need to be negative, >1mm, less than 10 mm. 2-3 mm usually recommended Post excision Imaging - specimen mammogram and/or - post lump mammogram Relative Contraindications 1 – in 2 or more quadrants 2 – diffuse or malignant appearing Ca++ 3 – persistent + margins 4 – not RT candidates prior RT pregnancy CTD – lupus/scleroderma Possible for low risk lesion, but “low risk” difficult to define

31. Management Options – Radiation Therapy Excision Alone – recommended Post Mastectomy – unnecessary No effect on mortality Decreases Breast Recurrence Risk by 50% (1% ½%/yr) Treatment is to Breast Only Contraindications: Omitted in low risk? controversial < 5mm, low grade, unicentric Relative Contraindications 1 – in 2 or more quadrants 2 – diffuse or malignant appearing Ca++ 3 – persistent + margins 4 – not RT candidates prior RT pregnancy CTD – lupus/scleroderma

32. NON INVASIVE LOBULAR Features Increased risk of subsequent invasive cancer (~ 1%/yr) Likely to be bilateral Management Options Observation ( negative surgical margins NOT required) No SLNBx or ALND is necessary Bilateral mastectomies can be considered Potential candidates for Tamoxifen or chemoprevention trials Work-Up/Follow-Up Bilateral mammogram, then yearly Exam every 6-12 months

33. INVASIVE Stages I – IIB + IIIA (T3 > 5 cm, N1 only) Management Priorities Surgery Adjuvant Chemotherapy Hormonal Rx* Radiation Rx*

34. CERVICAL CANCER

35. Where is the cervix?

36. Cervical cancer is the second most common cancer among women and is the primary cause of cancer-related deaths in developing countries Cervical cancer, in women, is the second most common cancer worldwide, next only to breast cancer. In India, cervical cancer is the most common woman-related cancer, followed by breast cancer Introduction

37. Cancer of the cervix is the most common female genital cancer in developing countries. Every year about 500,000 women , acquire the disease and 75% are from developing countries. The cervical cancer burden in India alone is estimated to be 100,000 .

38. The number of deaths due to cervical cancer is estimated to rise to 79,000 by the year 2010. The cancer mostly affects middle- aged women (between 40 and 55 years), especially those from the lower economic status who fail to carry out regular health check-ups due to financial inadequacy. In urban areas, cancer of the cervix account for over 40% of cancers while in rural areas it accounts for 65% of cancers as per the information from the cancer registry

39. INCIDENCE

40. Risk factors and aetiology HPV (Human papilloma virus ) infection mainly 16,18 the main aetiological is infection with subtypes of HPV (16,18 ) Coitus at young age: <16 years old increased risk by 50% Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds. Smoking Smoking for> 12 years increase the risk by 12.7 folds Previous CIN

41. Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids. Barrier method decrease the risk Immuno suppresive pt Low socioecomic class

42. Type of patient: Multiparous. Low socioeconomic class. Poor hygiene. Prostitute.

43. Predisposing factors: Cervical dysplasia. Cervical intraepithelial neoplasia CIN III / CARCINOMA IN SITU THE LESION PROCEEDS THE INVASION BY 10-12 YEARS The cervical cancer burden in

44. Symptoms: Early symptoms Late symptoms - None. - Thin, watery, blood tinged vaginal discharge frequently goes unrecognized by the patient. - Abnormal vaginal bleeding Intermenstrual Postcoital Perimenopausal Postmenopausal - Blood stained foul vaginal discharge. - Pain, leg oedema. - Urinary and rectal symptoms dysuria haematuria rectal bleeding constipation haemorrhoids - Uraemia

45. Pathology type Squamous cell carcinoma- 90%. Adenocarcinoma- 10%.

46. What do you know about cervical cancer screening?

47. What is a Pap test? Can find abnormal changes on the cervix. Treating early changes can prevent cancer of the cervix.

48. Pap test…

49. Cervical cancer prevention Pap smears performed once per year until age 30 >30 yrs - once every 3 yrs if pap and HPV negative 75% reduction in cervical cancer in countries with adequate screening

50. STAGES OF CANCER CERVIX Once cancer cervix is found (diagnosed), more tests will be done to find out if the cancer cells have spread to other parts of the body. This testing is called staging. TO PLAN TREATMENT, A DOCTOR NEEDS TO KNOW THE STAGE OF THE DISEASE.

51. TREATMENT Surgical. Radiotherapy. Radiotherapy & Surgery. Radiotherapy and Chemotherapy followed by Surgery. Palliative treatment.

52. Surgical procedure The classic surgical procedure is the wertheim’s hystrectomy for stage Ib,IIa, and some cases of IIb in young and fat patient

53. PROGNOSIS Depends on: Age of the patient. Fitness of the patient. Stage of the disease. Type of the tumour. Adequacy of treatment.

54. THE OVERALL 5 YEARS SURVIVAL FOLLOWING THERAPY: Stage I -------80% Stage II-------50-60% Stage III-------30-40% Stage IV-------4%

55. HPV-associated Conditions HPV 16, 18 Cervical cancer High/low grade cervical abnormalities Anal, Vulvar, Vaginal, Penile Head and neck cancers HPV 6, 11 Low grade cervical abnormalities Genital warts RRP Estimated % 70% 30%-50% 10% 10% 90% 90%

56. Human Papillomavirus Vaccines HPV4 (Gardasil) contains types 16 and 18 (high risk) and types 6 and 11 (low risk) HPV2 (Cervarix) contains types 16 and 18 (high risk) Both vaccines are supplied as a liquid in a single dose vial or syringe Neither vaccine contains an antibiotic or a preservative

57. Human Papillomavirus Vaccines HPV4 vaccine is approved for females 9 through 26 years of age for the prevention of cervical cancers, precancers and genital warts males 9 through 26 years of age for the prevention of genital warts HPV2 vaccine is approved for females 10 through 25 years of age for the prevention of cervical cancers and precancers not approved for males or for the prevention of genital warts

58. HPV Vaccine Schedule and Intervals HPV4- 0, 2, 6 months HPV2- 0, 1, 6 months ACIP recommends- 0, 1 to 2, 6 months ACIP has not defined a maximum interval between HPV vaccine doses If the interval between doses is longer than recommended continue the series where it was interrupted

59. Conclusions Cervical cancer affects women in our community Cervical cancer is a serious disease Risks just from preventing cancer 30% mortality from cervical cancer Long term effects after treatment for cervical cancer Cervical cancer is preventable Regular pap smears HPV vaccination

60. THANKYOU