1. Gynaecological Cancers
Malcolm Padwick MD FRCOG

2. Cervical Cancer

3. Cervical Cancer 1992 national targets set for year 2000
1. Reduce mortality by 20%
2. Achieve 80% smear uptake
1991 targets had already been achieved
Mortality rate had been falling since 1950 at a rate of 1 -2 % per annum
Now 2.3 per

4. At risk groups Young (immature TZ)
Early age of first sexual intercourse
Multiple partners
Smoking
Type of contraception
Screening history

5. Screening intervals (2004)
Age Group (years)
Frequency of Screening 25
First invitation
3 yearly
5 yearly
65+
No screen since age 50 yrs or recent abnormal smear

6. HPV HPV subtyping will become available
Concentrate screening on genuinely at risk women
Allow an increase in the screening interval
Avoid unnecessary intervention

7. Referral to Colposcopy
3 inadequate smears
2 mildly dyskariotic / borderline smears
First moderately or severely dyskariotic smear
Glandular abnormalities
Suspicion of malignancy

8. Colposcopy visit Information sheets with appointment
Separate clinic waiting area
Changing and washing facilities
Separate consultation area
Comply with NHSCSP appointment waiting times
Comply with NHSCSP waiting times for results

9. Scale of problem Therefore a follow-up policy change introduced (NHS)
Watford referrals 1995
228 new patients
Watford referrals 2003
618 new patients
Therefore a follow-up policy change introduced (NHS)

10. Colposcopy Assess Biopsy and act on results when available
See and treat

14. After effects 3 weeks of diminishing blood stained discharge
Risk of secondary infection at 1 week
Next period often heavy and painful
Overall post operative pain is minimal
>98% have a clear or better smear result at 6 months

15. Cervical cancer From colposcopy General clinic with abnormal bleeding
Acute admission with symptoms of advanced disease

16. Staging
EUA and cystoscopy
Pelvic MRI
Abdominal and chest CT

19. Treatment Surgery Cone biopsy Radical trachylectomy
Radical hysterectomy
Neoadjuvant chemotherapy combined with radical surgery
exenteration

20. Treatment Chemo-radiation as a primary treatment
Radiotherapy as post operative treatment for poor prognostic disease
Chemotherapy or radiotherapy for palliation

21. consequences Surgery Acute complications Fistula Bladder dysfunction
Body image
General improvement with time.

22. consequences Chemoradiation Alopecia Radiation burns
Vaginal stenosis and inflammation
Cystitis and colitis
Fistula bowel and bladder
Side effects tend to get worse with time.

23. The future Improved prevention Less invasive treatment for pre-cancer
vaccination

24. outcome
Stage I II
III IV
5 year survival
80%
60%
20% 5%

25. Malcolm Padwick MD FRCOG
Gynaecologist
West Herts NHS Trust

26. Ovarian Cancer

27. General impression Middle class disease Effects older population
Silent killer
One of the diseases GPs fear missing the most
Mortality 12 per

28. At risk groups Post menopausal Nulliparous
Family history (including breast cancer)
Contraceptive usage
Endometriosis
Environmental

29. Screening Genetic - BRCA 1 and 2 mutations General population
USS and CA125 ?????
Prophylactic oopherectomy after 40 years
+/- HRT
General population
USS and CA125 ?????
Research projects only

30. presentation Abdominal distension Abnormal PV bleeding
Abdominal discomfort
Dyspepsia
Bowel symptoms
From physicians and general surgeons

31. Investigations
CA125
USS
laparoscopy CT
MRI

34. Management MDT Surgery +/- chemotherapy
Staging and randomization into interval debulking study
Interval debulking
Pregnancy associated mass

36. Follow-up
CA125 CT
Relapse chemotherapy
Relapse surgery

37. Outcome
Stage I II
III IV
5 Year survival
90%
70%
25% 5%

38. Future ?

39. Endometrial Cancer
Malcolm Padwick

40. Endometrial Cancer 65 of all cancers in women postmenopausal
obese (hypertensive, diabetic)
HRT
tamoxifen

41. Symptoms PMB IMB PCB Pap smear Pain
Weight loss, bowel and bladder changes
Abnormal bleeding on HRT

42. Managment
Refer to the “rapid access clinic”
Use cancer pro forma

43. Investigations Pelvic USS
If endometrial signal > 4mm for endometrial biopsy -- either pippelle or hysteroscopy and currettage
High risk symptoms go straight to H & C