cervical cancer

1. CERVICAL CANCER
DR. R. RAJKUMAR D.M.
MEDICAL ONCOLOGIST
VELAMMAL SPECIALITY HOSPITALS

2. TOPICS
 EPIDEMIOLOGY
 ANATOMY
 RISK FACTORS
 DIAGNOSIS
 STAGING
 TREATMENT
 PREVENTION

3. Cervical
Cancer
• Cervical Cancer is
the second most
common cancer
among women
worldwide.
• Over 500,000 women
worldwide die of
cervical cancer
annually.
• Approximately every
47 minutes a
woman is

6. CERVICAL CANCER AFFECTS WOMEN IN THEIR PRIME
WHEN THEY ARE NEEDED BY THE FAMILY
Rates per 100,000 women per year
Annual number of cases and age-specific incidence rates of
cervical cancer in India
. [Accessed on 16th April 2018]
The Incidence of
Cervical cancer
in India is
highest
amongst 40-64
yrs women

7. THE COVERAGE OF CERVICAL CANCER SCREENING
IS VERY LOW IN INDIA
The cervical cancer screening coverage is a mere 2.6% in
the general female population
Bruni L, Barrionuevo-Rosas L, Albero G, Serrano B, Mena M, Gómez D, Muñoz J, Bosch FX, de Sanjosé S. ICO Information Centre on HPV and Cancer (HPV Information
Centre). Human Papillomavirus and Related Diseases in India. Summary Report 27 July 2017. [Accessed on 16th April 2018]

8. 8 |
2020-2030 Acceleration plan towards elimination
The 2030 targets and elimination threshold are subject to revision depending on the outcomes of the
modeling and the WHO approval process
Vision: A world without cervical cancer
Goal: below 4 cases of cervical cancer per 100,000 woman-years
90%
of girls fully vaccinated
with HPV vaccine by 15
years of age
70%
of women screened with
an HPV test at 35 and 45
years of age and 90%
managed appropriately
30%
reduction in mortality
from cervical cancer
2030
TARGETS

9. ANATOMY

12. Risk
Factors
Cervical
Cancer
• HPV
infection:
Sexually
transmitte
d virus
HPV infections are very common.
Most men and women who are sexually active have
been exposed to HPV. Over 85% of men and
women have been infected with HPV at some time
in their lives, but most infections clear up on their
own. More than 75% of sexually active women
have been exposed to HPV by age 18-22. Some
types of HPV can cause changes to cells in the
cervix. If these changes are found early, cervical
cancer can be prevented by removing or killing the
changed cells before they can become cancer
cells.
• Lack of
regular
Cervical
Smear
tests:
Cervical cancer is more common among women
who don’t have regular smear tests. The smear
test screens for abnormal cells. Removing or
killing the abnormal cells usually prevents cervical
cancer.
• Family History
• Smoking:
Heredity/ Genetics
Smoking cigarettes increases the risk of cervical
cancer.

13. Risk
Factors
Cervical
Cancer
• Using birth
control pills for
a long time:
Using birth control pills for a long time (5
or more years) may slightly increase the
risk of cervical cancer. However, the risk
decreases quickly when women stop
using birth control pills.
• Having many
children:
Studies suggest that giving birth to many
children (5 or more) may slightly increase
the risk of cervical cancer among women
with HPV infection.
• DES
(diethylstilbestr
ol):
DES may increase the risk of a rare form
of cervical cancer in daughters exposed
to this drug before birth. DES was given
to some pregnant women between 1940
and 1971.
(It is no longer given to pregnant women)
Having a HPV infection or other risk factors does not mean that
a woman will develop cervical cancer. Most women who have
risk factors never develop it. Women who have never been
sexually active and who have not had the HPV virus can also

14. About 80% of Women
will be infected with
HPV in their lifetime
HPV AND CERVICAL CANCER
Source: Gynecologic Cancer Foundation

15. About 7% of
Women have
an abnormal
smear test
HPV AND CERVICAL CANCER

16. HPV AND CERVICAL CANCER
Cervical cancer remains one of the gravest threats to women’s
lives
Cervical cancer is caused by high-risk types of HPV;
HPV 16 and 18: most common high-risk HPV types
Responsible for approximately 70% of cervical cancer cases.
HPV is currently the most common sexually transmitted
infection (STI)
80% of women can be infected at some point in their lifetime;
Most of infection clear naturally

17. WOMEN REMAINS AT RISK FOR
ACQUIRING HPV INFECTION
THROUGHOUT THEIR LIFETIMES

18. Sympto
ms
Cervical
Cancer
Early cervical
cancers usually
don’t cause
symptoms.
When the cancer
grows larger, women
may notice one or
more of these
symptoms.
Infections or other
health problems may
also cause these
symptoms.
A woman with any of
these symptoms should
tell her doctor so that
problems can be
Abnormal vaginal bleeding
—Bleeding that occurs between regular
menstrual periods
—Bleeding after sexual intercourse,
douching, or a
pelvic exam
—Menstrual periods that last longer
and are heavier than before
—Bleeding after going through menopause.
Increased vaginal
discharge
—Pelvic pain
—Pain during sex

19. DIAGNOSIS
CERVICAL SMEAR
COLPOSCOPY
CERVICAL BIOPSY

20. 20 |
VIA (1 of 2): Background
 Visual Inspection with Acetic Acid (VIA) is a technique for the detection
of pre-cancerous or cancerous lesions in the cervix.
 The application of dilute acetic acid on such lesions triggers whitening of
these regions.
 VIA is a relatively simple, low-cost
method presenting immediate results.
 A positive result can be followed by
immediate treatment (i.e. single-visit
approach).
 VIA is subjective and depends on the
skills and experience of the provider.
VIA Screening Results:
Negative Positive
Image source: Jhpiego, 2015

21. 21 |
 Glacial (water-free) acetic acid is the base for this medium; household
white vinegar is another source of concentrated acetic acid.
 A 5% acetic acid solution must be used.
 A pharmacist, chemist or chemical supplier can make dilute (5%) acetic
acid according to the following:
– Use glacial acetic acid (water-free acetic acid) or acetic acid with known
concentration (above 5%)
Total parts of water = [% concentrate/% dilute] − 1
– E.g. preparing a 5% solution from a 20% concentrated acetic acid solution:
Total parts of water =
20%
5%
− 1 = 3 → 3 parts water to 1 part
concentrate, by volume
VIA (2 of 2): Technical Specification Guidance

22. COLPOSC
OPY
A visual examination of the
surface of the cervix using a
colposcope- an instrument
with magnifying lenses and a
light.
If abnormalities are seen, a
tissue sample (biopsy) may
be taken and sent for
evaluation.

23. 23 |
Colposcope (1 of 3): Background
 A colposcope is an instrument that provides strong light and magnifies a
field, allowing specific patterns in the epithelial (surface) layer and
surrounding blood vessels to be examined.
 Colposcopes are used on patients with positive screening results, to:
– verify the presence, extent, and type of pre-cancer or cancer;
– to guide biopsies of any areas that appear abnormal; and,
– to help determine more appropriate treatment (cryotherapy, LEEP, or TA).
 Colposcopy requires highly trained providers and is not an appropriate
screening tool, nor is colposcopy a required step between screening and
treatment.
 More recently, colposcopes are being designed as handheld, specialized
video or digital camera tools.

24. 24 |
Colposcope (2 of 3): Strengths and limitations
 Colposcopy can be used to guide a biopsy of an
abnormal area.
 Colposcopes are expensive, specialized pieces of
equipment.
 Colposcopy is resource intensive; it requires provider
training, specialized equipment and pathology services.
 It should not be used as a screening method.
 If the procedure is not readily available, this can create
bottlenecks in the system, leading to patients being
lost to follow-up.

25. 25 |
Colposcope (3 of 3): Technical Specification Guidance
 Optical magnification: 2x-15x, continuous or discrete.
 Working distance: 300 mm.
 Manual or autofocus.
 Colposcope head including eyepiece distance should be high and
maneuverable.
 Must be attached to a stand or easily fixed onto a stand for hands-free
visualization during treatment.
 Light source: halogen or LED, with green light filter.

26. May feel like getting a smear test or
like a menstrual cramp that lasts a
few seconds
Biop
sy

27. Detection and
Diagnosis
Cervical
CancerIf abnormal cervical smear or HPV results are found other
tests will be carried out to make a
diagnosis:
Colposcopy
:
A colposcope is used to look at the cervix. The
colposcope combines a bright light with a magnifying
lens to make tissue easier to see. A colposcopy is
usually done in the doctor’s office or clinic.
Biopsy: Biopsy under local anesthesia and pathologists then
check the tissue under a microscope for abnormal
cells.
Punch biopsy: The doctor uses a sharp tool to pinch off small
samples of cervical tissue.
LEEP: The doctor uses an electric wire loop to slice off a thin,
round piece
of cervical tissue.
Endo-cervical curettage: The doctor uses a curette (a small,
spoon-shaped instrument) to scrape a small sample of tissue
from the cervix. Some doctors may use a thin, soft brush
instead of a curette.
Conization: The doctor removes a cone-shaped sample of
tissue. A conization, or cone biopsy, lets the pathologist see if

28. PATHOLOGY TYPE
• Squamous cell carcinoma- 90%.
• Adenocarcinoma- 10%.
TYPES OF GROWTH
• Exophytic: is like cauliflower filling up the vaginal
vualt.
• Endophytic: it appears as hard mass with a good
deal of induration.
• Ulcerative:an ulcer in the cervix.

31. Cervical
Cancer
• Stage I: The tumor has invaded the cervix beneath the top layer
of cells. Cancer cells are found only in the cervix.
• Stage II: The tumor extends to the upper part of the vagina. It
may extend beyond the cervix into nearby tissues
toward the pelvic wall (the lining of the part of the
body between the hips). The tumor does not invade
the lower third of the vagina or the pelvic wall.
• Stage III: The tumor extends to the lower part of the
vagina. It may also have invaded the pelvic
wall.
If the tumor blocks the flow of urine, one or both
kidneys may not be working well.
• Stage IV: The tumor invades the bladder or rectum.
Or the cancer has spread to other parts of the body.
• Recurre
nt
cancer:
The cancer was treated, but has returned after a period
of time during which it could not be detected. The
cancer may show up again in the cervix or in other
Stagin
g

33. Grades of
Dysplasia
Normal
CIN 1 = Mild dysplasia
CIN 2 = Moderate
dysplasia CIN 3 =
Severe dysplasia

34. Stage
IA

36. Stage
IIA
Stage
IIB

37. Stage
IIIA
Stage
IIIB

38. Stage
IVA
Stage
IVB

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

40. Treatment options for
CIN
Treatments include:
• LEEP
• Laser
• Cryotherapy
• Cone Biopsy
• Hysterectomy
may be
recommended

42. 42 |
Cryotherapy (1 of 3): Background
 Cryotherapy eliminates precancerous areas on the cervix by applying a
highly cooled metal disc (cryoprobe) to the cervix and freezing the
abnormal areas (along with normal areas) covered by it.
 Supercooling of the cryoprobe is accomplished using a coolant gas
(either compressed carbon dioxide, CO2, or nitrous oxide, N2O), thus
relies on a complex supply chain.
 Cryotherapy can be performed immediately after screening, usually by a
wide range of trained health care providers across all levels of the health
system, and has long been the standard in LRS.
 It takes ~15 minutes and is generally well tolerated, associated with only
mild discomfort, and thus does not require anaesthesia. The treated area
takes about a month to regenerate.

43. 43 |
Cryotherapy (2 of 3): Strengths and limitations
 The equipment is simple &
relatively inexpensive.
 Electricity is not required.
 In the context of a screen & treat approach, a
screen-positive result can be followed by an
offer of treatment at the same visit, maximizing
treatment coverage and reducing loss to follow-up.
 This treatment method does not produce a specimen
for pathological examination.

44. 44 |
Cryotherapy (3 of 3): Technical Specifications Overview
 Can be consoles or stand-alone or handheld units.
 The probe has a closed system in which the cryogen travels to and
circulates in the probe head, then back through probe for exhausting.
(An open system is not suitable for CO2 and N2O)
 Contact between supercooled metal probe tip and epithelium results in
tissue necrosis. The following table indicates treatment temperatures:
Source: Colposcopy and Treatment of Cervical Cancer, IARC 2017

45. 45 |
Thermal Ablation (1 of 3): Background
 Thermal ablation has been used effectively in some settings for many
years, especially for the treatment of endometriosis.
 Thermal ablation uses low heat to destroy lesions.
 It has limited side-effects, is inexpensive compared with other treatment
options, it is not dependent on a continuous supply chain, and is
technically simple to implement.
 Only recently have handheld devices come on the market, making the
method more suitable for LRS (benchtop models are cumbersome and
reliant on mains, though highly effective).
 Thermal ablation can be performed immediately after screening, by a
range of trained healthcare providers across all levels of health systems.

46. 46 |
Thermal Ablation (2 of 3): Strengths and limitations
 The equipment is simple &
relatively inexpensive.
 External gas is not required.
 Electricity is not necessarily required; can function
off of portable batteries/power-supply.
 In the context of a screen & treat approach, a
screen-positive result can be followed by an offer of
treatment at the same visit, maximizing treatment
coverage and reducing loss to follow-up.
 This treatment method does not produce a
specimen for pathological examination.

47. 47 |
Thermal Ablation (3 of 3): Technical Specification Guidance
 Handheld (rechargeable) or benchtop (plug-in)
 Compatible for use with at least two probes with different-sized tips
– Standard tip diameters: 16 mm and 19 mm
– A flat tip and a tip with a nipple for placement into the cervical canal
 Heat to 100-120°C and has a depth penetration of 4-7mm
 Typical duty cycle:
– 8 seconds of heat up;
– 20-45 seconds of treatment; and
– 10 seconds to cool down.
 Tips should be easily decontaminated, cleaned, and sterilized or
disinfected between patients.

48. 48 |
LEEP (1 of 3): Background
 LEEP – Loop Electrosurgical Excision Procedure – is the removal of
abnormal areas from the cervix and the entire transformation zone using:
– A thin wire loop powered by an
electrosurgical unit (ESU), which
cuts and coagulates at the same
time; after which,
– A ball electrode is used on the
tissue to complete the coagulation.
– Tissue removed can be sent for
examination to the histopathology
laboratory, allowing the extent of the lesion to be assessed.
 The procedure can be performed under local anesthesia on an outpatient
basis and usually takes 10-15 minutes; however, a patient should stay in-
facility for a few hours to assure bleeding does not occur.
3
2
1
3
2
1

49. 49 |
 LEEP is a relatively simple surgical procedure, but it should only be
performed by an intensively trained health-care provider with
demonstrated competence in the procedure
 Recognizing and managing intraoperative and postoperative
complications, such as bleeding or infection is crucial; LEEP is best carried
out in at least secondary-level facilities where backup care is available.
 The histology specimen can have charred borders, making lesion margins
difficult to interpret.
 LEEP:
– Relies on dependable, quality power supply
– Uses sophisticated equipment that requires maintenance.
LEEP (2 of 3): Strengths and limitations

50. 50 |
LEEP (3 of 3): Technical Specifications Overview
 Equipments needed: ESU (with probes), colposcope,
optional (UPS), speculum
 ESU specification for LEEP:
– Reliable power supply. Metal casing case. Foot pedal
control
– Function:
• coagulation mode: up to 80 W / 150 Ω, cutting mode: up
to 110 -200 W / 300 -400 Ω;
• LEEP specific: blended current option available,
coagulation maximum > 60 W, cutting maximum > 60 W.
– Electrode: wired, various sizes and shapes (minimum
ball electrode, square loop electrode, semicircular loop
electrode), made of stainless steel or tungsten wire.
WHO comprehensive guide to cervical cancer control, 2014

52. Treatment for Cervical
Cancer
Cervical
Cancer Women with cervical cancer
have treatment
options.
The options are
Surgery
Radiation
Therapy
Chemotherapy
or a combination
of methods.
The choice of treatment depends
mainly on the size of the tumor and
whether the cancer has spread. The
treatment choice may also depend on
whether the woman wishes to become
pregnant someday.
Cancer treatments often damage
healthy cells and tissues, so side
effects are common.
Side effects may not be the same for
each person, and they may change
from one treatment session to the
next.

53. ? ?
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6

54. Cervical
Cancer
Surgery is an option for women with Stage I or II
cervical cancer. The surgeon removes tissue that may
contain cancer cells:
 Radical
Trachelecto
my:
Removal of the cervix, part of the vagina, and the
lymph nodes in the pelvis.
Recommended for a small number of women with
small tumors who may want to try to get pregnant
in the future.
 Total
Hysterectom
y:
Removal of the cervix and uterus.
 Radical
Hysterectom
y:
Removal of the cervix, some tissue around the
cervix, the uterus, and part of the vagina.
 Fallopian
Tubes
and Ovaries:
The surgeon may remove both fallopian tubes and
ovaries.
This surgery is called a salpingo-oophorectomy.
 Lymph Nodes:
The surgeon may remove the lymph nodes near
the tumor to see if they contain cancer.
If cancer cells have reached the lymph nodes, it
Surge
ry

55. Radiation
Therapy
Cervical
Cancer
Radiation therapy (radiotherapy) is an
option for women with any stage of
cervical cancer.
• Early stages of cervical cancer can be
treated with radiation therapy instead of
surgery.
• It may also be used after surgery to destroy any
cancer cells that remain in the area.
• Cancer that extends beyond the cervix
may have radiation therapy and
chemotherapy.

56. Cervical
Cancer
Doctors use two types of radiation therapy to treat
cervical cancer.Some women receive both
types:
 External
Radiatio
n
Therapy
:
A large machine directs radiation at the pelvis or
other tissues where the cancer has spread. The
treatment usually is given in a hospital or clinic.
External radiation usually takes place 5 days a week
for several weeks.
Each treatment takes only a few minutes.
 Internal
Radiatio
n
Therapy
:
A thin tube is placed inside the vagina. A radioactive
substance is loaded into the tube. The patient may
need to stay in the hospital while the radioactive
source is in place (up to 3 days). Or the treatment
session may last a few minutes, and the patient can
go home afterwards.
Once the radioactive substance is removed, no
radioactivity is left in the body. Internal radiation may
be repeated two or more times over several weeks.
Radiation
Therapy

57. Chemothera
py
Cervical
Cancer
For the treatment of cervical cancer, chemotherapy is
usually combined with radiation therapy.
However depending on the type of cancer
chemotherapy can also be used alone.
Chemotherapy uses drugs to kill cancer cells.
Cytotoxic medication prevents cancer cells from
dividing and growing.
The drugs for cervical cancer are usually given
through a vein
(intravenou
s).
Chemotherapy can take place at a clinic, at the
doctor’s surgery, or sometimes at home.
Some women need to stay in the hospital during
treatment
.

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Treatment Algorithm

59. Indication for post op radiation
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62. Types of radiotherapy
TELETHER
APY
BRACHYTHER
APY
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63. GOALS
High dose to tumor tissue-Tumor
control
Normal tissue sparing
Minimize long and short term
toxicities
Better Quality of life
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64. Evolution of Treatment Techniques
CONVENTIONAL
RT
Collimator shapes Beam
Rectangular Treatment
Field
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Shaped Treatment
Field
1970s

65. IMRT
• Divides each treatment field
into multiple segments
• Modulates beam
intensity, giving discrete
dose to each segment
• Uses multiple, shaped beams
(~9) and thousands of
segment
s
IMRT Initiated in
1995 Reached the clinic in
2000

66. • Short distance /contact with
tumor
• Expertise needed
• Invasive procedure
• Adequetly sparing normal
structure
• Well established
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Brachytherapy

67. HDR ICA
APPLICATORS
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68. MUPIT IMPLANT IN CA
CERVIX
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69. Follow-up
Care
Regular checkups after treatment for
cervical cancer are important. Checkups
help ensure that any changes in health
are noted and treated.
Doctor’s will check for the return of
cancer. Even when the cancer seems to
have been completely removed or
destroyed, the disease sometimes returns
because undetected cancer cells
remained somewhere in the body after
treatment. Checkups include a physical
exam, cervical smear tests, bloods and
chest x-rays.
Cervical
Cancer

70. PREVENTION

71. LIFE COURSE APPROACH TO CERVICAL
CANCER PREVENTION AND CONTROL
Girls 9-14 years
• HPV vaccination
Girls and boys, as appropriate
•Health information and warnings about tobacco
use
•Sexuality education tailored to age & culture
•Condom promotion/provision for those engaged
in sexual activity
•Male circumcision
Women > 30 years of age
“Screen and treat” – single visit approach
• Point-of-care rapid HPV testing for high risk
HPV types
• Followed by immediate treatment
• On site treatment
All women as needed
Treatment of invasive cancer at any age and
palliative care
•Ablative surgery
•Radiotherapy
•Chemotherapy
•Palliative Care
Primary Prevention Secondary Prevention Tertiary Prevention

72. Prevention is better than
cure

73. • To be most effective, the HPV vaccine should be given before any
type of sexual contact occurs with another person.
• Recommendations for each age group:
• Girls ages 11 to 13
The vaccine should be given to girls aged 11 to 13 and the HSE has
offered the HPV vaccine to all girls in first year in second level
schools since 2010 to protect them from cervical cancer in
adulthood
• Girls ages 13 to 18
Girls ages 13 to 18 who have not yet started the vaccine series or
who have started but have not completed the series should be
vaccinated.
• Young women ages 19 to 26
Some authorities recommend vaccination of women ages 19 to 26, but
the American Cancer Society experts believed that there was not
enough evidence of the benefit to recommend vaccinating all women
in this age group.
HPV Vaccine
Who should be vaccinated and
when?

74. The Quadrivalent Human
Papillomavirus Vaccine
(QHPV)

75. GARDASIL®
The Only Quadrivalent HPV Vaccine1
• The vaccine is composedof Virus
like particles (VLP) for HPV types
6, 11, 16, 18
• Manufactured in Saccharomyces
cerevisiae
• Amorphous aluminum
hydroxyphosphate sulfate
(AAHS) adjuvant – 225 μg per dose
• 3 dose (0, 2 & 6) or 2 dose (0 & 6) month
dosing regimen
• Does not contain viral DNA
and therefore doesn’t cause
infectious
Gardasil PI India MSDIN 10/16

76. GARDASIL
Quadrivalent
HPV Types 6 11 16 18
Indicated age and
gender
Female 9-45 years old
Cervical cancer,
Indicated for Vulvar cancer,
preventing… Vaginal cancer,
Genital warts
Gardasil PI India MSDIN 10/16
29

77. DOSAGE FOR ALL
GARDASIL®
should be administered intra muscular in the deltoid
region of the upper arm or in the higher anterolateral area of the
thigh as 3 separate 0.5-mL doses according to the following
schedule:
• First dose: at elected date
• Second dose: 2 months after the first dose
• Third dose: 6 months after the first dose
Individuals are encouraged to adhere to the
0, 2, and 6 months
vaccination schedule.
Vaccination
Months 0 1 2 3 4 5 6 7 8
(The second dose should be administered at least one month after
the first dose and the third dose should be administered at least 3
months after the second dose. All three doses should be given
Gardasil PI India MSDIN 10/16

78. Gardasil is now approved for use in an
alternative 2 dose schedule in India for
9 –14 yr old girls
Females 9 to 14 years of age:
• Gardasil can be administered according to a
2-dose schedule at 0, 6 months.
(If the second vaccine dose is administered earlier than 6 months after the
first dose, a third dose should always be administered.)
• Alternatively, Gardasilcan be administeredaccording to a
3-dose schedule as described previously
0 1 2 3 4 5 6 7 8
Vaccinatio
n
Months
Gardasil PI India MSDIN 10/16

79. Genital
Warts2
Vulvar/ Vaginal
Precancers
(Grade 1- 3)2
Cervical Cancer &
Precancers (Grade 2/
3)1
99
%
98
%
100
%
HPV induced lesions
Protectio
n
1. The Future II Study Group. Lancet
2007; 369: 1861–68 2.Garland
SM et al. New Engl J Med. 2007;356:1928–
Efficacy of Quadrivalent/ Bivalant HPV Vaccine:
BIVALA
NT
cervari
x
√
X
√

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