1. Cervical Cancer Can we prevent it?
Dr Paul Byrne MD FRCOG FRCPI
Department of Obstetrics & Gynaecology
Rotunda Hospital & Beaumont Hospital

2. Overview Cervical cancer- what is it? Epidemiology
Natural history of cervical neoplasia
Prevention of cervical cancer
Cervical “Pap” smears
Abnormal smears
Treatment of cervical cancer
Vaccination

6. Epidemiology Commonest cancer in women in developing countries
The second most common cancer in women worldwide
The eight most common cancer diagnosed in women in Ireland

7. Ranking of the most commonly diagnosed invasive cancers in women 2007-2009
Organ
Rank %
Breast 1
32.3%
Colorectal 2
11.4%
Lung 3
9.5%
Melanoma 4
4.7%
Corpus Uteri 5
4.3%
Lymphoma 6
4.0%
Ovary 7
3.8%
Cervix 8
3.5%
Pancreas 9
2.6%
Stomach 10
2.2%
National Cancer Registry (Ireland)

8. Average Annual Incidence of cancer diagnosis 2007-2009
Organ
Number of cases
% of all cancers
Breast
2673
32.3%
Cervix
287
3.5%
National Cancer Registry (Ireland)

9. Annual Cancer Deaths 2006 Organ Deaths (female) Mortality Rate
Breast (1st)
678
30.4
17.5%
Lung (2nd)
Colorectal (3rd)
Ovary (10th)
659
419
275
28.6
16.3
12.4
17.1%
10.8 %
7.1%
Cervix (19th) 83
4.2
2.1%
National Cancer Registry (Ireland)

11. Transformation Zone Squamous epithelium Columnar epithelium
Squamo-columnar junction

12. Cervical Transformation Zone
Columnar Epithelium  (metaplasia)  Squamous epithelium

13. Natural History of Cervical Neoplasia
Columnar Epithelium (metaplasia)  Squamous epithelium
Oncogenic Stimulus

14. Natural History of Cervical Neoplasia
Columnar Epithelium (metaplasia)  Squamous epithelium
Oncogenic Stimulus
CIN
Cancer

15. Natural History of Cervical Neoplasia
Columnar Epithelium (metaplasia)  Squamous epithelium
HPV
Nicotine
Oncogenic Stimulus
CIN
Cancer

16. Natural History of Cervical Neoplasia
NORMAL  CIN1 CIN 2 CIN 3 INVASION
HPV

17. Natural History of Cervical Neoplasia
NORMAL  CIN1 CIN 2 CIN 3 INVASION
NICOTINE

18. Cervical Intraepithelial Neoplasia (CIN)
SIL
Squamous Intraepithilial lesion

20. Cervical Neoplasia - A sexually transmitted disease
Cervical cancer
Rarely seen in women who have never had sexual intercourse
Risk of developing cervical cancer is related to:
Early age at first intercourse
Number of partners
HPV is sexually transmitted
Cervical neoplasia occurs when the cervical transformation zone is exposed to HPV

21. Human Papillomavirus (HPV)
A double stranded DNA virus that infects squamous epithelia where it causes warts and tumours
100 different types of HPV
HPV types 6 and 11 cause approximately 90% of genital warts
Genital warts are highly contagious - two-thirds of people who have sexual contact with an infected partner will develop warts
HPV types 16 and 18 cause approximately 70% of cervical cancers

22. Prevention of deaths from cervical cancer
Primary prevention
Vaccination
Secondary prevention
Cervical cytology
CervicalCheck screening programme
Early Diagnosis
Down staging of cancers at diagnosis
Agreed assessment and referral for women with symptoms

23. Screening for Cervical Neoplasia
Cancer of the cervix is unusual compared to other cancers…………
Prolonged precancerous phase
The cervix is accessible
Precancerous phase is detectable
(“Pap smear”)
Proven success of population screening

24. Introduction of a national cervical screening in Ireland
- September 2008

25. “Based on a target uptake of 80 per cent, a successful national, quality assured cervical screening programme has the potential to significantly reduce mortality rates in the screened population by as much as 80 per cent by the end of the second full screening round in 2014”

26. Irish National Cervical Screening Programme
Provides free smear tests to women aged 25-60:
-every 3 years for women aged 25 to 44
-every 5 years for women aged 45 to 60
Women with abnormal smears are referred for colposcopy

27. Colposcopy Low power magnification of the cervix
Assess the transformation zone
Detect CIN
Treat CIN

28. Abnormal Transformation zone
CIN3
Normal transformation zone

29. LLETZ procedure Large Loop Excision of the Transformation Zone
Local anaesthesia
Treatment of CIN 2 & 3, and persistent CIN1
“See and Treat”
Follow up with annual smears for 10 years

30. Colposcopy and LLETZ Procedure

31. Treatment of Cervical Cancer
Stage 1b & 2A
Radical Hysterectomy
Also known as Wertheim Hysterectomy
Total abdominal hysterectomy, parametria, upper third of vagina, pelvic lymph nodes.
Ovaries need not be removed, especially in younger women.
Higher morbidity than simple hysterectomy
Advanced stages
Radiotherapy +/- Chemotherapy

32. Survival Stage 5-year survival Ia1 90% Ia2-Ib2 85% II 60% III 40% IV
15%

33. Schools HPV Vaccination Programme in Ireland
The HPV vaccine will protect against 70% of cervical cancers.
HPV Vaccination commenced in May 2011.
Vaccination programme is delivered by HSE Immunisation teams nationwide.
The programme will target all girls in 1st year of second level schools.
Gardisil is the vaccine of choice, three doses are required over 6 months.

34. Cervical Cancer- a preventable disease.
Exam Question…………………
Cervical Cancer- a preventable disease.
Discuss.