Cervical Cancer Educational Presentation
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Cervical Cancer Educational Presentation
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Cervical Cancer Educational Presentation
- 1. Cervical Cancer Prevention· Screening· Evaluation · Treatment
- 31. Abnormal Pap test – How common is it? 10,000 cancers 300,000 HSIL (High-Grade precancerous lesions 1.25 million LSIL (Low-Grade precancerous lesions) 2-3 million ASC (Atypical Squamous Lesions 50-60 million women screened
- 42. Recommended age groups of the cervical cancer vaccine? *The effectiveness of vaccine may be reduced in this age group. The vaccine is less effective with more prior HPV exposure. Girls 9-10 Eligible for the vaccine Girls 11-12 Recommended age group to receive the cervical cancer vaccine Girls 13-18 Eligible to receive the vaccine, if not previously vaccinated for cervical cancer Women 19-26 * Eligible for the vaccine, if not previously vaccinated for cervical cancer Women 27-older Not FDA approved Men Not FDA approved
- 49. Clinical staging of cervical cancer Source: “FIGO Annual Report on The Results of Treatment in Gynaecological Cancer” Journal of Epidemiology and Biostatistics , (2001) vol. 6 no. 1, page 14.
- 54. Cervical cancer: What is the chance of survival after treatment? FIGO Stage 5-Year Survival Stage I 81-96% Stage II 65-87% Stage III 35-50% Stage IVA 15-20%
- 61. Gynecologic Cancer Foundation 230 W. Monroe Suite 2528 Chicago, IL 60606 800-444-4441 www.wcn.org [email_address]
Notas del editor
- Cervical cancer is one of the few malignancies that can be prevented through screening. In this presentation you will learn about established and new methods of screening. Screening has saved hundreds of thousands of American lives. Every woman listening to this presentation should get regular cervical cancer screening—[meaning that they should have regular Pap tests and HPV tests when recommended by a healthcare provider.] This is a preventable cancer!
- Cancer still drastically changes the lives of many women in the U.S., but with the empowerment through knowledge, more women are participating in prevention and screening activities that are reducing the risk of dying of these diseases. Cervical cancer rates are still far higher than they should be since over half of the women with this diagnosis have not had a Pap test in over three years. This educational material is designed to improve participation in screening practices through a better understanding of benefits.
- Where Pap tests are not available for screening, cervical cancer is the number one cancer killer of women. Cervical cancer typically affects women at younger ages than other gynecologic cancers. That’s why we [especially??] urge all reproductive-age women to educate themselves and to participate in screening. [MARK—are Pap tests recommended for women until age 70?] The Pap test has reduced the risk of cancer by early detection of cells destined to become cancer.
- The vulva is the female external genitalia, just outside the vagina. The vagina is located between the vulva and the bottom of the womb (the cervix). The cervix is responsible for keeping babies inside the womb until the baby is mature enough for delivery. The uterus is where the fertilized eggs implant and it houses babies for nine months. It is also responsible for menstrual cramps through its muscular contractions. The fallopian tubes transport eggs and sperm. The ovary is responsible for monthly production of eggs [in reproductive age women] as well as for hormone production. Because there are often no symptoms with early cervical cancer and a woman cannot see her own cervix, regular cancer screening examinations are important to find early changes.
- The cervix is the communication between the vagina and the uterus that keeps babies inside until their due date and provides transport for sperm to get to the uterus. The cells on the outside of the cervix are squamous mucosa, like the vagina and the inside of your mouth. The cells on the inside of the cervix are glandular and are responsible for the production of mucous, like the inside of your nose. Cervical cancers tend to occur where the two cell types meet; we call this the transformation zone. Cancers can come from the squamous or the glandular cells. The glandular cancers hide deeper in the cervix and are harder to detect.
- Most women who have cervical cancer have not had Pap tests regularly. About 75% of U.S. women had a Pap test in the past three years. Cervical cancer is uncommon in this group of screened women. Abnormal results of the Pap test are common and do not always mean precancer. Women should talk with their health care provider about any abnormal results. Do not be afraid. Effective treatment is available if needed.
- The cause of cervical cancer is a sexually transmitted virus, called the human papillomavirus. There are many HPV types and only some cause cancer. HPV infections (even high-risk types) usually go away without treatment. Low-risk HPV types can cause genital warts. It is the high-risk types cause most abnormal pap tests, precancer and cancer of the cervix, vagina and vulva.
- Most men and women who have HPV never know they are infected. HPV can be detected by a DNA test. Women with infections that do not go away for years are at highest risk of precancer and cancer. HPV testing is relatively new, and many women will first hear about this virus when they have an abnormal Pap test or a positive HPV test. If you don’t have HP, you are at low risk for developing cervical cancer. If you test positive for HPV, talk to your health care provider about the next steps. You are not alone. This is a very common infection.
- This is a very common virus. Studies show that most sexually active women have had HPV at some time. In fact, HPV infection is so common in women ages 18-29, that current recommendations for screening advise against testing women in this age group.
- Most women are at risk since sex is a normal adult activity. The more partners a woman has the greater her chances of being infected with HPV. Studies show that even women who report one lifetime sexual partner have about a 10% chance of having HPV infection. We really don’t know everything about how this virus is transmitted. [Mark, we say that it is sexually transmitted, so this seems a contradiction.]
- The risk for cervical cancer increases with each additional factor listed. All of our bodies have the ability to fight infections. Some of our bodies are more effective fighters of HPV than others. A weakened immune system from any cause makes the body less able to fight the virus. Women who smoke are more likely to get cervical precancer and cancer. Tobacco may contribute to cervix cancer risk in multiple ways. First, tobacco decreases the bodies ability to fight off infections like HPV. Second, some of the [cancer-causing] chemicals found in tobacco are concentrated in the mucous made by the cervical glands. When a woman who smokes has an HPV infection, the carcinogens and the virus are a “double hit” for her cervix.
- The longer you wait to have sex, the fewer partners you are likely to have, thus reducing your risk for cervical cancer. Your partner’s partners also can increase your risk. If you already smoke, talk to your health care provider about programs to help you stop. Good nutrition helps strengthen your immune system and allows the body to dilute the effects of cancer-causing agents. Some research suggests that adequate folic acid, found in foods such as uncooked spinach, romaine lettuce, rice, lentils and, believe or not, Cap’n Crunch, can reduce your risk of cervical cancer. Condoms do decrease the spread of HPV as well as other sexually transmitted diseases, so use them. Most importantly, if Pap tests are performed regularly, you will be identified as having a problem before it is life threatening, in most cases. Now, a new vaccine can additionally help protect you from developing cervical cancer. If your healthcare provider recommends it, get the cervical cancer vaccine. [Mark--why not say if you are between 9-26, get vaccinated. We have not applied the healthcare provider caveat elsewhere.}
- When you have a Pap test, your healthcare provider scrapes cells from the cervix and places them on a microscope slide or into a jar containing liquid. Laboratory tests are run to find out if there are any abnormal cells. [Mark—do we need to mention here that liquid testing is more accurate??] If abnormalities are found, you will be notified to return for repeat testing. If precancer changes are found, they are easily treated, but follow-up is necessary. Unlike mammograms, chest X-rays and the PSA test for prostate cancer, Pap tests can detect changes before cancer develops.
- Many women assume that if they have a pelvic examination, they also are getting a Pap test. This is not always the case. Ask you healthcare provider how often you should be tested given your age, medical and sexual history. Make a file and put all of your Pap tests results in it for future reference. This test is just a screening test for cervix cancer. It is not a good test for other types of cancer. There is currently no recommended test for uterine or ovarian cancer, unless you have a strong family history of cancers. If you want more information about other cancers, go to www.wcn.org. January is Cervical Cancer Screening Month. It is a good time to schedule your annual exam.
- Current knowledge suggests it takes at least three years for cervical cancer to develop. Since cervical cancer is sexually transmitted, you should have your first Pap test three years after you have sex or when you are 21, whichever comes first.
- The American Cancer Society recommends annual Pap tests until age 30. If the new liquid-based test is used, you can be screened every two years. Women 30 and older may be screened every two to three years if you have three normal tests in a row. If the new combination HPV and Pap test is used, you can wait three years between Pap tests [if your results are normal.]
- The purpose of the Pap test is to find problems before symptoms occur. Once symptoms occur, the success rate for treatment goes down. It is possible to prevent cervical cancer because precancers can be detected with Pap tests and treatment can be started.
- New testing options are making Pap test more accurate. However, it is still possible for an abnormality to be missed. Repeat testing improves the odds of finding any abnormalities. It is possible to have your first Pap test abnormality many years after you had sex with an infected partner. Realize also that a woman’s risk can change. You may have a new sexual partner or your partner may have a new partner.
- A routine Pap test should be performed between periods. If you are having abnormal bleeding, make an appointment as soon as possible. Keep your appointment because the bleeding may be a sign of cancer.
- Like any new experience, you may wonder what will happen during your first Pap test. If you have concerns during the test, tell your healthcare provider. Even if you find a Pap test embarrassing or mildly uncomfortable, it is worth it.
- You can feel in control of your health by taking responsibility for knowing the results of all of your tests. Be sure you receive your results. Do not assume that a lack of a letter or phone call, means everything is ok. If you have not received your results in a reasonable amount of time, call your provider’s office. Remember that you know your body best. If something doesn’t seem right, even if you have had a normal Pap test, make an appointment with your healthcare provider.
- The American Cancer Society recommends that you have a Pap test four to six months after your hysterectomy if your surgery was done for moderate to severe dysplasia or cancer. If you have three normal Pap tests in a row following your hysterectomy, you may discontinue Pap tests. If you had a hysterectomy, and did not have a previous cancer or precancer, you are at very low risk. A Pap test is not recommended, but other preventive health care is still important.
- If you are 70 or older with a history of normal results, you are at very low risk of cervical cancer and do not need Pap test. If you have sex with a new partner, this may change your risk. Talk to your healthcare provider about if and when you need a Pap test.
- Women who are younger may have the liquid-based Pap test, which only needs to be repeated every two years. The Pap test also might be sent to a computer for confirmation of a negative result. [Mark—why are we saying only younger—do we mean only women who still have periods??] If you are 30 or over, it may be useful to combine the HPV DNA test Mark—do we need to say DNA test here?]with a Pap test. It tells you if the cells look normal and if high-risk HPV DNA [ditto] is present. The combination of these tests only needs to be repeated every three years if both tests are negative [or normal?]. Sometimes, the Pap test is now read by new computer reviews. This technology is an added ‘safety-net’ for review of your Pap test. Not all providers offer Pap test imaging. You should talk with your healthcare provider about these advances in cervical cancer prevention. If you decide to have one of the new screening tests, you might want to make sure it will be covered by your insurance plan. Also, not all providers offer all the tests yet. Additionally, your provider may offer to include the cervical cancer vaccine, if you are eligible.
- In the United States, approximately 50 million women undergo a Pap test each year. Of those, about 7-8% will have an abnormal result. This pyramid shows the break-down of Pap test abnormalities by frequency: About 2 million women have atypical squamous cells (ASC), 1.25 million have low-grade abnormalities (LSIL), about 300,000 have high-grade abnormalities (HSIL) and about 12,000 have cervical cancer each year. This pyramid also indicates the breakdown of abnormal Pap tests by by their proximity to normal or cancer. The higher up you go, the worse the abnormality. Fortunately, the most common abnormal findings on a Pap are minimally abnormal changes or low-grade abnormalities with the high-grade pre-cancer or cancer changes being much less frequent. [Mark—I assume these numbers are still accurate?]
- An HPV test is sometimes useful to determine if you need any further evaluation. This is particularly true for the minimally abnormal Pap tests with atypical squamous cells of undetermined significance, often abbreviated as ASC-US. The HPV test is collected just like a Pap test. In fact, if the Pap test is collected in a liquid, then the HPV test can be run on that liquid if the Pap test shows minimally abnormal results. The test checks for high-risk HPV. The FDA approved HPV DNA test (DNA with Pap [no longer used—just HPV test] can identify 13 different high-risk HPV types. About 90% of cervical cancers are caused by one of these 13 types.
- There is a spectrum of Pap test results from “normal to “cancer or carcinoma.” In between normal and cancer, there is a range of abnormalities, such as ASC-US (the abbreviation for atypical squamous cells of undetermined significance) or LSIL (low-grade squamous intraepithelial lesions) to more significant cellular changes, such as HSIL (high-grade squamous intraepithelial lesions), AGC (atypical glandular cells) or AIS (adenocarcinoma in situ). A Pap test is only a screening test. Additional tests are needed to determine if there is indeed a pre-cancer change or cancer. The abnormalities called ASC-US sometimes harbor pre-cancer changes, but most often reflect inflammation, hormonal changes or an infection with the human papillomavirus. If your Pap test shows ASC-US, any of the following three management options may be chosen as the next step by you and your doctor: HPV testing, repeat Pap tests at approximately six month intervals or immediate colposcopy. The other abnormalities are almost always caused by HPV. Thus, testing for HPV is not helpful in those cases. The more abnormal tests, such as HSIL, AGC, AIS, and cancer are also more worrisome for true pre-cancer or cancer changes. Any of these Pap test results should be followed by a colposcopy with biopsies. For AGC, an endometrial biopsy may be added. [If cancer is suspected or diagnosed, see a gynecologic oncologists. A gynecologic oncologist is a physician who specializes in the care of women with [reproductive cancers] precancers or cancers and would often be consulted if the Pap test shows AIS or cancer. [Mark—we are trying to say it this way, but am can use the previous language if you prefer.]
- The first step in the evaluation of an abnormal Pap test is a colposcopy. Colposcopy is a test that helps find abnormal areas in the cervix. This is done in the doctor’s office. Similar to the examination for obtaining a Pap test, a speculum will be placed into the vagina. A nurse or doctor then applies a vinegar-like solution onto the cervix and examines the cervix with the colposcope, which is a magnifying lens with a strong light. If there are abnormal areas, a biopsy may be taken. [This implies that nurse do colposcopies—is this true?]
- During a biopsy, a very small piece of tissue is removed so that a pathologist can evaluate it under a microscope to make a diagnosis. Any visible abnormality of the cervix should be biopsied to make sure of the diagnosis. Having a biopsy taken may cause some discomfort, like a menstrual cramp that lasts a few seconds. Sometimes, your doctor will also perform an endocervical curettage, in which a little bit of tissue will be scraped from the cervical canal in order to examine it more closely under the microscope. And, at times colposcopy with biopsies and endocervical curettage is not enough to find the explanation for the abnormal Pap test and to make sure of the diagnosis. In this situation, a conization is performed, during which a larger, cone-shaped piece of tissue is removed from the cervix.
- The pathologist examines all tissues under the microscope. Similar to what was discussed earlier for the Pap test, biopsy results can show a broad spectrum with the two extremes being “normal” and “cancer or carcinoma” . In between, there is a range of abnormalities called CIN I to III. CIN stands for cervical intraepithelial neoplasia. CIN III is a pre-cancer change. This means the cells are highly abnormal, but do not yet invade or spread like cancer cells. It is important to understand that treatment depends on the biopsy results, NOT the Pap test. For CIN I management options include treatment or observation. Which route of management is right for you will depend on a number of factors. Observation is often preferred over immediate therapy since the chance that CIN I spontaneously regresses to normal is about 60%. However, about 10% will progress to more severe abnormalities. Therefore, a schedule of repeat examinations will be needed when CIN I is diagnosed, often Pap tests every six months. CIN II and III should always be treated. If any invasive cancer has been found, you should be seen by a gynecologic oncologist to determine what treatment you will need.
- If you need treatment for CIN, there are multiple treatment options such as LEEP, laser, cryotherapy, and cone biopsy. Options can be divided into two main groups: those that remove the area of abnormality (LEEP, cone biopsy) and those that destroy the area of abnormality (cryotherapy, laser vaporization). Each of those have their indications, advantages and disadvantages, but, importantly, cure rates are comparable. In special circumstances, a hysterectomy may be recommended.
- Cryotherapy, LEEP, laser and conization are similar in their ability to treat CIN. Estimated cure rates range from 73% to 90% with a single treatment. However, 10% to 27% of patients will have future problems with CIN, making close follow-up after treatment very important. Once a patient has been treated for CIN, her risk for developing invasive cervical cancer is about 1%. One major concern regarding treatment of cervical pre-cancers has been the potential that fertility may be decreased. Treatment of CIN could make it more difficulty to get pregnant or to carry the baby to full-term. This could happen because of cervical stenosis (scarring of the opening of the womb), decreasing cervical mucous formation or cervical incompetence (weakening of the cervix with difficulties of holding the baby inside the womb until term). It is important to notify your obstetrician regarding your history of cervical surgery if you have a future pregnancy.
- You can feel in control of your health by taking responsibility for knowing the results of all of your tests. Be sure you receive your results. Do not assume that a lack of a letter or phone call, means everything is ok. Remember that you know your body best. If something doesn’t seem right, even if you have had a normal Pap test, make an appointment with your healthcare provider. Also- DO NOT SMOKE!
- In June 2006, a new vaccine was approved by the US Food and Drug Administration (FDA). This vaccine can help prevent cervical cancer by providing protecting you from the ‘high-risk’ HPV virus types that cause 70% of cervical cancer. This vaccine is approved for girls and women ages 9-26. The benefit of the vaccine declines with increasing HPV exposure.
- Girls age 11 and 12 should routinely be vaccinated. Vaccination can be started as young as age 9. Girls age 13-18 should receive the vaccine if they have not already been vaccinated. Women ages 19-26 are eligible to receive the vaccine, but it may not work depending on your prior exposure to HPV. The vaccine will not protect everyone, so it is important to continue getting cervical cancer screening with a Pap test [and a HPV test when recommended by your healthcare provider.} The vaccine is not approved for women over 26 and men. [Mark, should we add the phrase “at present” to signal that this may change?]
- If you started having sex, the vaccine benefit may be lower for you. Also, the vaccine has limited benefit if you are already infected with HPV. Early vaccination, regular Pap tests and HPV tests when recommended by a healthcare provider will provide you with your best protection against cervical cancer.
- Getting the vaccine is easy. You will have a shot followed by another 2 months later and another 4 months after that. Sometimes it may hurt for a few days after the shot. If you are pregnant or trying to get pregnant, do not get the vaccine.
- Usually women with cervical cancer have no symptoms, particularly if the cancer is small. The common symptoms of cervical cancer are: Bleeding between periods Bleeding or spotting after sexual intercourse Bleeding or spotting in women who have already gone through menopause Unusual, continuous, foul-smelling vaginal discharge In women with more advanced cervical cancer additional symptoms may occur, such as: Progressive and ultimately constant pelvic pain One-sided leg pain caused by nerve involvement A pelvic mass Bleeding from the bladder or rectum. It is not unusual for a woman with cervical cancer to have no symptoms.
- Often times cervical cancer is first diagnosed by a primary care provider. Once the diagnosis is suspected or confirmed, the primary care provider will help find a gynecologic oncologist. These physicians are expert in the diagnosis and treatment of cervical cancer. Women with cervical cancer are encouraged ask about clinical trials. Co-operative group trials are performed at many institutions around the country and your gynecologic oncologist can suggest appropriate trials. [Woman also can log onto the Women’s Cancer Network (www.wcn.org) to review the clinical trials section for available clinical trials.] Radical hysterectomy and chemoradiation are the most common treatments for cervical cancer. Even with a diagnosis of cervical cancer, a woman may have the option of preserving her ability to have children and to keep her ovaries.
- There are many treatment options for cervical cancer. It all depends on how big it is, your medical history and your concerns for future fertility. You should discuss your treatment options with a gynecologic oncologist.
- The clinical stage is the extent of cancer at the time of diagnosis. Staging is necessary so that physicians can accurately communicate with each other about the disease. This allows doctors to discuss treatment options, to consider enrollment in clinical trials and to compare the outcomes in efforts to improve quality of care. Clinical staging [should be performed by a gynecologic oncologist and] is completed before treatment begins. Cervical cancer can be broken into 4 general groups. Stage I Stage IA cancers are cancers with minimal invasion that can only be detected microscopically. Stage IB cancers are those that involve only the cervix. The cancers that are larger than 4 cm are classified as stage IB2. Stage II A stage IIA cervix cancer indicates that there has been spread of the cancer to involve both the cervix and upper portion of the vagina. A cancer is defined as stage IIB if there is extension of the cancer into the tissue next to the cervix. Stage III A stage IIIA cervical cancer has involvement of the lower vagina and a IIIB has extension of the cancer towards the pelvic sidewall. Stage IV Stage IV cancers involve the bladder, rectum, lungs or other organs.
- A cervical conization is often used to diagnose or exclude the presence of a very small cervical cancer. This procedure is performed in the operating room with or without general anesthesia where a cone shaped segment of the cervix is removed. Alternatively, a large cervical excisional biopsy can be performed in the office under local anesthesia. The risks associated with a cervical conization are bleeding, infection and infertility.
- If a hysterectomy must performed for the treatment of cervical cancer, a radical hysterectomy is usually performed. This involves removal of the uterus along with a portion of the surrounding support tissue and a portion of the upper vagina. The lymph nodes in the pelvis and sometimes those near the aorta are removed. The radical nature of the procedure results in a few more complications when compared to a simple hysterectomy. The most common changes are noted in the function of the bladder (you can’t tell when your bladder is full, so you must watch the clock to know when to go), shortening of the vagina and constipation. A radical hysterectomy does not require removal of the ovaries.
- If you have an early cancer and you desire future fertility, a radical trachelectomy may be an option for you. The cervix and the surrounding tissues are removed without removing the uterus. So you still have a womb to carry a pregnancy. This treatment option may not be for you- discuss this with a [your] gynecologic oncologist.
- For some women, treatment with chemoradiation is a better option than surgery. This is most often true with advanced cancer. Radiation is composed of two portions, external and internal radiation. A very low dose of chemotherapy is administered at the same time as the external radiation. This low dose of chemotherapy makes the radiation therapy more effective. External radiation is usually given in small doses five days a week for about five weeks. Fatigue, nausea, diarrhea, and skin or vaginal irritation are common side effects. For internal radiation, a radiation cylinder is placed inside the vagina where it delivers radiation treatment directly to the cervix. This procedure can last several hours to a full day in the hospital. Several treatments may be necessary.
- The survival rate five years after diagnosis varies depending upon the stage of cervical cancer. The risk increases with higher stages of disease. However, there are treatment options for everyone.
- [Be patient with yourself as you re-establish your wellness. This journey is different for each woman, but some women find strength from family and friends as well as support from others, including counseling. Exercise is good emotional therapy and good for the healing process. If you have any questions about what exercise is best for your, talk to your healthcare provider.]
- The most important thing that any woman can do to prevent cervical cancer is to have a Pap test regularly! It is very important to educate our friends about the importance of a Pap test. There are many reasons women postpone having a Pap test. Help your friend by reassuring her that a Pap test does not hurt. Give her a ride to get the Pap test. Offer to help with child care. Help her identify a health care provider or clinic so that she can make an appointment for her Pap test.