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

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

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

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)

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)

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)

Transformation Zone Squamous epithelium Columnar epithelium Squamo-columnar junction

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

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

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

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

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

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

Cervical Intraepithelial Neoplasia (CIN) SIL Squamous Intraepithilial lesion

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

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

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

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

Introduction of a national cervical screening in Ireland - September 2008

“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”

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

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

Abnormal Transformation zone CIN3 Normal transformation zone

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

Colposcopy and LLETZ Procedure

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

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

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.

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