1. Cervical Cancer and it’s Prevention

2. Our Topics For Today 1.What is a Cervix? 2.What is Cervical Cancer? 3.Why is it important? 4.What causes it? 5.What are the symptoms of Cervical Cancer? 6.How is it treated? 7.Related diseases 8.How can you protect yourself? 9.What you should know about screening 10.What you should know about vaccination

3. What is a Cervix?

4. What is cancer? Normal: Normal cells multiply all the time Old cells die and fall off New, completely formed, mature cells replace them They take over the regular function Cancer…..normal gone berserk: Normal mechanism can be disturbed by many factors (ex: virus, chemicals in Tobacco, repeated damage) Cancer cells are abnormal cells which multiply too fast Old cells refuse to die New cells don’t mature but keep growing – become a bulk called “tumour” Cannot function normally and start competing with the normal cells Can spread and grow anywhere else in the body and choke off the normal cells (ex: brain, lungs, liver)

5. What is Cervical Cancer? Cancer that affects the “mouth” of the uterus

6. What the doctors see at each stageAn actual photograph What does Cervical Cancer look like?

7. What causes Cervical Cancer? A virus HPV (Human Papilloma Virus)

8. HPV 16HPV 18HPV 6 HPV 11 >75% of Cervical Cancer 5,6 >50% of Vaginal & Vulvar Cancer 5 90% of Anogenital warts 5 1.Schiffman M, Castle PE. Arch Pathol Lab Med. 2003;127:930–934. 2. Wiley DJ, Douglas J, Beutner K, et al. Clin Infect Dis. 2002;35(suppl 2):S210–S224. 3. Muñoz N, Bosch FX, Castellsagué X, et al. Int J Cancer. 2004;111:278–285. Reprinted from J Virol. 1994;68:4503–4505 with permission from the American Society for Microbiology Journals Department. 4. Walboomers JM, Jacobs MV, Manos MM, et al. J Pathol. 1999;189:12–19. 5. X. Castellsagué, S. de Sanjose, T. Aguado, K. S. Louie, L. Bruni, J.Muñoz, M. Diaz, K. Irwin, M. Gacic, O. Beauvais, G. Albero, E. Ferrer, S. Byrne,F. X. Bosch. HPV and Cervical Cancer in the World. 2007 Report. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Available at: www.who.int/hpvcentre6. Bhatla N et al.Vaccine (2008;26; 2811-17www.who.int/hpvcentre6 The 4 most important types of HPV

9. HPV infections – what you should know Large number of women get HPV infection sometime during life time (80% by the age of 50). There are no symptoms – you may not know you have it Majority would clear infection without developing any disease. Few women develop precancerous lesions and cervical cancer over a period of time (few months to 9 years). We don’t know which ones will!

10. Why is Cervical Cancer important to you? > 200 women die every day in India 1 woman every 7 minutes 8 women die every hour Cervical Cancer is the commonest cancer in Indian Women

11. Why is Cervical Cancer important to you? New cervical cancer cases diagnosed annually India : 1,32,082 World : 4,93,243 Deaths due to cervical cancer annually India : 74,118 World : 2,73,505 Rest of World - 73% India - 27% 1. X. Castellsagué, S. de Sanjose, T. Aguado, K. S. Louie, L. Bruni, J.Muñoz, M. Diaz, K. Irwin, M. Gacic, O. Beauvais, G. Albero, E. Ferrer, S. Byrne, F. X. Bosch. HPV and Cervical Cancer in the World. 2007 Report. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Available at: www.who.int/hpvcentre India makes up only 16% of the world’s population But has 27% of the world’s total cervical cancer cases and deaths every year

12. 1. X. Castellsagué, S. de Sanjose, T. Aguado, K. S. Louie, L. Bruni, J.Muñoz, M. Diaz, K. Irwin, M. Gacic, O. Beauvais, G. Albero, E. Ferrer, S. Byrne, F. X. Bosch. HPV and Cervical Cancer in the World. 2007 Report. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Available at: www.who.int/hpvcentre Far more common than other cancers in Indian women

13. What are the Symptoms of Cervical Cancer? Usually no symptoms in early stage When advanced, there can be the following symptoms: A little bleeding between periods Bleeding after sexual intercourse Abnormal vaginal discharge Sometimes – pain During intercourse Continuous Low back-ache Unexplained loss of weight Pail face and nails (anemia)

14. How is Cervical Cancer Treated? Treatment options depend on the following: The stage of the cancer. The size of the tumor. Your age. Your desire to have children.

15. Early Stage Cervical Cancer Conservative treatment (save the uterus and part of the cervix) Burn the abnormal part of cervix with electric current (electro-cautery) Destroy the abnormal area by freezing it (cold co-agulation) Excellent chance of saving life Can have babies (may have some difficulty)

16. Later Stage of Cervical Cancer Surgery 1.Medium spread of cancer – remove uterus with cervix, tubes and ovary Good chance of survival Can’t have babies 2.Late Stage Extensive surgery removing other parts of the body as well Needs radiation therapy and chemotherapy Chances of survival vary

17. Related Diseases HPV causes other diseases: Vaginal pre-cancer Vaginal cancer Vulva pre-cancer Vulvar pre-cancer Genital Warts vulva

18. *Ray K et al, Indian J Med Res 2006; 124: 559-568 – Population studied – STD clinic OPDs 18% 6% 11% 10.5% 0 2 4 6 8 10 12 14 16 18 20 1990-931994-971998-012002-04 Study Period Percentage Genital Warts are on the rise in India

19. How can you protect yourself? Awareness VaccinationScreening

20. What you should know about screening: “PAP’s smear” Simple, quick painless procedure – takes 5 minutes How is it done? A smooth, sterilized instrument is gently inserted to see the cervix A small spatula or brush is swiped across the cervix to loosen cells The brush is smeared on a clean glass slide The slide is later examined by an expert to spot abnormal cells This test should be done every year after onset of sexual relationship till the age of 64 Should be done within 10 days of the end of your period

21. What you should know about vaccination Vaccination is the only true form of “prevention” – stops the disease from happening in the first place There are two vaccines available today: Quadrivalent (“four type”) Protects from 6,11,16,18 Partial protection from 33, 35, 41 and 7 other types Bivalent (“two type”) Protects from 16, 18 Partial protection from 33, 35 and 41

22. What you should know about vaccination How does the vaccine work? It gets your body to produce antibodies against the HPV virus. These antibodies protect your body from an HPV infection by fighting the virus when it tries to attack the cervix. Who should take the vaccine and when? Ideally, the vaccine should be taken as early as possible after the age of 9 years but girls and women of any age up to 45 can benefit from this vaccine. Expectant mothers should not take the vaccine during their pregnancy.

23. What you should know about vaccination What is the dose schedule of the vaccine? The quadrivalent vaccine is given in three doses as follows: Now 2 mths 6 mths I I I In special cases ( ex: impending marriage or travel, planning a pregnancy soon etc.), the doctor can "abbreviate" the schedule to 0,1 and 4 months. The bivalent is given in a similar schedule at 0,1 and 6 months. How soon will the protection work? Usually, the full protection comes into effect usually within a month of the last dose. It is important to complete the schedule. How long will the protection last? So far the data has shown that vaccinated women have been significantly protected from the disease since they got the vaccine (8.5 yrs according to published data).There is a good chance of life-long protection as well. Only time will tell. This is being tracked worldwide till we know for sure when people would need a booster, if at all. What about side effects? The vaccines have been studied and is safe and well tolerated.

24. What have you learnt today? Cervical Cancer is the most common cancer affecting Indian women It is a preventable disease You can protect yourselves and your daughters and be almost 100% safe with a combination of vaccination and screening

25. Thank you Please ask Questions

26. The Vaccines Quadrivalent Protects against 4 serotypes of the virus: 6, 11, 16, 18 Proven highly efficacious against the above Provides cross protection against 31, 33, 45 and seven other serotypes Proven safety Approved in India for protection against 6 diseases: Cervical Cancer and pre-cancers Genital Warts Vulvar pre-cancers Vulvar cancer Vaginal pre-cancers Vaginal cancer Approved for age group 9-45 yrs Not tested in pregnant women Proven safe in lactating mothers FDA approved Approved in 140 countries Costs Rs. 2800 per dose in India Bivalent Protects against 2 serotypes of the virus: 16, 18 Proven highly efficacious against the above Provides cross protection against 31, 33 and 45 Proven safety Claim for “higher immune response” not comparable (WHO) and impact on actual efficacy not proven Approved in India for protection against: Cervical Cancer and pre-cancers Approved for age group 10 to 55 yrs Not tested in pregnant women Not tested in lactating mothers Not approved by FDA Approved in 95 countries Costs Rs. 2000 per dose in India