SCREENING IN GYNECOLOGICAL CANCER Taravat Fakheri OB/GYN KUMS

26%Lung and bronchus 15%Breast26%Lung and bronchus 15%Breast 9%Colon and rectum 7%Pancreas 5%Ovary 4%Non-Hodgkin lymphoma 3%Leukemia 3%Uterine corpus 2%Liver 2%Brain 9%Colon and rectum 7%Pancreas 5%Ovary 4%Non-Hodgkin lymphoma 3%Leukemia 3%Uterine corpus 2%Liver 2%Brain

Cancer prevention Primary Prevention = Identification & modification of risk factors. Secondary prevention=Detection at an earlier more treatable stage. Tertiary prevention=Effective treatment of clinical disease.

Primary Prevention CA Cx 1=Barrier method 2=Decrease Tobacco 3=Diet high folate Vit B,B carotene. 4=HPV vaccine.

Primary Prevention CA Endo 1=Ideal body weight. 2=Low fat diet 3=Avoid unopposed estrogen in menaupose.

Primary Prevention CA Ovary 1=Use OC. 2=Avoid talk. 3=in gene carriers salpingo ophorectomy.

Secondary Prevention Detect disease at more curable stage In suitable disease & suitable screening test. suitable disease=Serious consequence Have preclinical phase. Preclinical long enough.

suitable screening test Simple Acceptable. Low cost High validity

Natural history of low-grade HPV cervical lesion Cervical HPV is very common, related to sexual behavior High spontaneous remission rate lower remission rate in CIN LSIL progress to HSIL in 70% in 10 yrs

HPV DNA Testing Together with Pap Smear every 2 year is beneficial cost benefit. Sensitivity =100%

Ovarian Tumors High mortality due to late diagnosis 75% of ca ovary at diagnosis were at late stage with a 28% 5 yr survival Stage I ca ovary has 95% 5 yr survival

Symptoms asymptomatic Lower abdominal pain/pressure mass Abdominal enlargement Vaginal bleeding Urinary/bowel symptoms

Risk factors 1)majority has no risk factor 2) family history 10% - familial ovarian syndrome 2)nulliparous 3)racial and social

Why screening for ovarian cancer is so difficult? Anatomic location of the ovary, not easily accesible Lack well defined precursor lesion and has poorly defined natural history Low prevalence, need exquisite specificity to avoid unnecessary intervention Lack of a good method

Serum CA125 Transvaginal ultrasonogram Multimodal New method under investigation.

Serum CA125 Elevated in 82% of ovarian cancer and <1% of healthy women rising pattern over time preceded ovarian cancer limitations: lack of sensitivity in Stage I disease, poor specificity (elevated in benign and other malignant conditions)

Ovarian Screening Not cost-effective May be considered in high risk population No place for population screening yet

Screening – US and CA 125 “…there is no evidence available yet that the current screening modalities of CA 125 and ultrasonography can be effectively used for widespread screening to reduce mortality from ovarian cancer…”

Only High risk population with BRCA1 or BRCA2 Have annual or semiannual screening with US & CA125.

Endometrial CA Incidence : third commonest malignant tumour of GT. Age : 58

High prevalence in the West, low (same as ovarian ca) precursor lesion, atypical endometrial hyperplasia accessibility of endometrium to sampling high cure rate for early disease Cons: majority detected at early stage because of abnormal bleeding esp PMB

Risk Factors DM, HT, obesity nulliparity, anovulation, late menopause exogenous estrogen endogenous estrogen smoking, white familial history

PMB 1) carcinoma of endometrium14% 2) other gynecological malignancy14% 3) atrophic endometritis20% 4) endometrial hyperplasia12% 5) cervicitis/erosion 8% 6) endometrial polyp 8% 7) cervical polyp

Tools explored – pelvic ultrasound (>8mm endometrial thickness in postmenopausal women) Karlsson 1995 – endometrial aspirate (inadequate sampling in menopausal women)

End cancer Screening Not justified in population screening. End BX or Sono in; Obese-Estrogen exposure-Tamoxifen-Hx colon & Endometrium Ca- is justified.

Conclusions Cervical cancer screening is the most successful programme in gynaecological cancers Ovarian cancer screening is not proven to be cost-effective yet, may be considered in high risk groups Endometrial cancer screening may be considered in high risk groups