Ca Cervix

Dr Monika Teresa Prasetyo

Dr Sienny Amelia Kwok

Cervix
Lower part of the
uterus
Connects the body of
the uterus to the
vagina (birth canal)

Source: American Cancer Society

Cervical Cancer
Begins in the lining of the cervix
Cells change from normal to precancer (dysplasia) and then to
cancer

Source: American Cancer Society

Statistics

10,520 new cases in the U.S. this year

3,900 will die
50% are diagnosed between ages 35 and 55.
20% at the age of 65 or over.
Rarely occurs in women younger than 20
Noninvasive is four times more common
74% decrease in deaths between 1955 and
1992 in the U.S.
Death rate continuous to decline by 2% a year
Source: American Cancer Society

Signs and Symptoms

Vaginal bleeding
Menstrual bleeding is longer and heavier than usual
Bleeding after menopause or increased vaginal
discharge
Bleeding following intercourse or pelvic exam
Pain during intercourse

Source: American Cancer Society

Risk Factors

Human papillomavirus infection (HPV) Primary factor

HPV 16, HPV 18, HPV 31, HPV 33, HPV 45
50% are caused by HPV 16 AND 18
Sexual behavior
Smoking
HIV infection
Chlamydia infection
Diet
Oral contraceptives
Multiple pregnancies
Low socioeconomic status
Diethylstilbestrol (DES)
Family history

Source: American Cancer Society

Prevention
Avoiding the risk factors
Especially HPV
Help for low-income women (NBCCEDP)

Having the Pap Test

3 years after first vaginal intercourse or by age
21.
Have test annually

Source: American Cancer Society

Diagnosis
Cervical Cytology (Pap Test)

Cells are removed from the cervix and

examined under the microscope.
Can detect epithelial cell abnormalities
Atypical squamous cells
Squamous intraepithelial lesions
Squamous cell carcinoma (likely to be
invasive)

Source: American Cancer Society

Diagnosis
Additional testing
Colposcopy
Cervix is viewed through a colposcope and
the surface of the cervix can be seen close
and clear.

Cervical Biopsies
Colposcopic biopsy removal of small
section of the abnormal area of the surface.
Endocervical curettage removing some
tissue lining from the endocervical canal.
Cone biopsy cone-shaped piece of tissue is
removed from the cervix

Survival Rate
5-year survival rate is 92% for earliest
stage
71% for all stages combined

Source: American Cancer Society

Treatment
Surgery

Preinvasive cervical cancer

Cryosurgery
Laser surgery
Conization
Invasive cervical cancer
Simple hysterectomy
Removal of the body of the uterus and cervix.
Radical hysterectomy and pelvic lymph node dissection
Removal of entire uterus, surrounding tissue, upper part of
the vagina, and lymph nodes from the cervix.

Radiation

Chemotherapy

Source: American Cancer Society

Epidemiologi
Kanker no 6 tersering di Amerika
Ditemukan 12.900 kasus baru tiap
tahun
Ada 4.400 orang yang meninggal
tiap tahun
Kanker no 2 di negara berkembang
Usia rata2 ditemukan saat usia 51
tahun

Penyebab
HPV 16 dan 18

Faktor Risiko

Penurunan sistem imunitas tubuh

HIV AIDS
Penyakit Menular Seksual
Merokok
Jumlah anak yang banyak
Penggunaan kontrasepsi yang
diminum

Gejala

Perdarahan
Keputihan
Nyeri panggul
Lesu
Penurunan berat badan
Pucat

Pencegahan
Vaksinasi HPV

Cervical Cancer
Prevention Screening
Evaluation Treatment

Cervical Cancer Screening

and Prevention

New cancer diagnoses

in the U.S.
2009 Statistics:

Breast
192,370
Uterus (womb)
42,160
Ovary
21,550
Cervix
11,270
Vulva
3,580

Source: American Cancer Society.

What is cervical
cancer?
It is a cancer of the female reproductive
tract
It is the most common cause of cancer
death in the world where Pap tests are
not available
It is the easiest gynecologic cancer to
prevent through screening and early
vaccination

What is the female

reproductive
tract?
Vulva

Vagina

Cervix

Uterus

Fallopian tubes

Ovaries

What is the cervix?

Opening of the
uterus (womb) into
the vagina
Two cell types
present (squamous
and glandular)
Cervical cancer
tends to occur where
the two cell types
meet

Source: TAP Pharmaceuticals,

Female Reproductive Systems.

How common is cervical

cancer?
500,000 women worldwide are diagnosed
with cervical cancer annually
50-60 million women in the U.S. have a Pap
test each year
3-5 million women in the U.S. have an
abnormal result usually due to precancer
changes on the cervix
Approximately 11,270 new cervical cancers
diagnosed in the U.S. per year
Over 4,070 deaths from cervical cancer in
the U.S.
year
Mostper
Cervical
Cancer Can Be Prevented

What causes cervical

cancer?
The central cause of cervical

cancer is human papillomavirus or

HPV:
HPV is transmitted through
sexual contact
The HPV detected today could
have been acquired years ago
There are many different types
of HPV that can infect the
cervix, vagina and vulva
Low-risk types may cause genital
warts
High-risk types may cause
precancer and cancer of the cervix

If I have HPV, does it

mean I will get cancer?
NO!
In most cases HPV infection will go away
Only women with persistent HPV (where the
virus does not go away) are at risk for
cervical cancer

How common is HPV?

Most men and women who have had sex
have been exposed to HPV
More than 75% of sexually active women
have been exposed to HPV by age 18-22

Who is at risk?
Women who have ever had sex
Women who have had more than one
partner
Women whose partner (s) has had more
than one sexual partner
Women who have had a sexuallytransmitted disease

Who is at risk?
Women who do not have Pap tests
Women with immune problems including
those who:

Use steroid medications on a

regular basis
Have organ transplant
Are undergoing chemotherapy
Are infected with HIV
Women who smoke.
Smoking all by itself increases the risk of HPV
infection and cervical precancer lesions, and

How do I lower my risk?

Delay onset of sexual activity or remain
abstinent
Know your sexual partner
Do not smoke
Maintain a healthy diet and lifestyle
Practice safe sex. Condoms decrease
the chance of HPV exposure.
If eligible, consider getting the vaccine
that prevents most cervical cancers.
Get your Pap test and HPV testing as
recommended by your health care
provider.

What is a Pap test?

A test which collects cells from the surface
of the cervix and looks for any abnormal
cells
Abnormal cells can be treated before
cervical cancer develops
When cancer is detected early, it is easier
to treat

What a Pap test is NOT!

A pelvic exam (You can have a pelvic
examination without a Pap test!)
A test for ovarian or uterine cancer
A biopsy

When do I need my first

Pap test?
At age 21, regardless of sexual activity
history

How often do I need a

Pap test?
Every 2 years for women aged 21-29
Women aged 30 years and older who have
had three consecutive Pap smear results
that are negative can be screened at
intervals of every 3 years.
Additionally women aged 30 and older, who
have a negative Pap smear and negative HPV
testing, can be screened every 3 years with
repeat Pap smear and HPV testing.

I feel fine, so why do I

need a Pap test?
A Pap test can find treatable changes of the
cervix (precancer) before you have a
symptom or notice a problem
Once a problem is symptomatic, it is harder
to treat

Why do I need to keep

getting tested?
The test is not perfect
Changes (abnormalities) may occur since
the last test
It may take many years for changes to
develop or be detected
Your risk changes if you have new partners

What is the best time to

have a Pap test?
Schedule your Pap when you are not having
a menstrual period
It is best to abstain from intercourse, and
avoid use of tampons or douches for 2 days
before your Pap test

What should I expect

when I have
a Pap test?
Feet are placed in stirrups (foot holders)
A speculum (thin duck-billed instrument
made of metal or plastic) is inserted into
vagina to see the cervix
You may have brief discomfort which is
usually mild
You may have some spotting afterward

How do I find out about

my Pap test results?
You may ask to have a copy mailed to you
You may call for your results. Be sure to
know your result.
If you have an abnormal result, it is
extremely important to follow-up for the
recommended testing
Even after a normal Pap test, it is still
important to report any symptoms of
abnormal vaginal bleeding, discharge or
pain to your doctor, and call to be seen right

Do I need a Pap test if I

had a hysterectomy?
If you had a hysterectomy for a non-cancer
disease, you may not need a Pap test. This
needs to be discussed with your healthcare
provider.
If you had treatment for precancer or
cancer of the cervix, you may need a Pap
test
If the cervix was left in place at the time of
your hysterectomy, you will still need Pap
tests

Is there an age when I

can stop having Pap
tests?
The American Cancer Society recommends
that screening stop at age 70 if three or
more recent tests are normal, and there
have been no abnormal results in the last
10 years.

What is new in screening

and prevention?
Liquid cytology-thin layer cytology. This is
where your cervical swab is placed in a
container instead of smeared on a slide.
Combination of HPV test and Pap is now
available for screening women 30 years of
age and older. This helps identify patients
at increased risk for developing cervical
cancer.
Pap test imaging by computer reviews in
addition to a review by trained personnel.

Evaluation of the Abnormal Pap

Test
and Treatment of Precancer

Abnormal Pap test How

common is it?
10,00
0
cancer
s
300,000 HSIL (High-Grade
precancerous lesions

1.25 million LSIL (Low-Grade

precancerous lesions)

2-3 million ASC (Atypical Squamous

Lesions
50-60 million women screened

What is an HPV test?

A test sometimes used to determine if you
need further evaluation
Cells are collected just like a Pap test
It checks for high-risk HPV

What happens if I have an

abnormal
Pap test?
Depending on your Pap test
result your provider may
advise one or more of the
following:

HPV testing
Repeat Pap
Colposcopy
Possibly an endometrial biopsy
Possible referral to gynecologic
oncologist

What is a colposcopy?
Colposcopy:
Use of a
magnifying
instrument
Application of a
vinegar-like
Source: This is a copyrighted image of the
Family Health Council, Inc. and may not
solution onto the California
be reproduced in any way without the expressed
written permission of the California Family Health
cervix
Council. California Department of Health Services
"What You Should Know if your Pap Test is
Shows
Abnormal"- Your Colposcopy Exam, Donna Bell
abnormalities
Sanders (Education Programs Associates 1995;
Campbell, CA).
that cant be
seen with the
naked eye
Feels like getting
a Pap test, but

What is a cervical
biopsy?
Biopsy:
Removal of a small
piece of tissue from
the cervix
May feel like
getting a Pap test
or like a menstrual
cramp that lasts a
few seconds
Source: A. DeCherney and M.
Pernoll, Current Obstetric and
Gynecologic Diagnosis and
Treatment (The McGraw-Hill
Companies, Inc.) 586.

Source: TAP Pharmaceuticals,

Female Reproductive
Systems.

What does the biopsy

result mean?
Mildly abnormal (CIN I)

Usually you will be watched closely

to see if your body can fight the
infection
More abnormal (CIN II)

Usually you will be scheduled for

treatment or watched closely
Precancer (CIN III)

Usually requires office or outpatient

treatment
Cancer

Usually followed by a consultation

with a gynecologic oncologist

What are the treatment

options for CIN?
There are a variety of effective
options for treatment. Most are
outpatient or office treatments.
Treatment names that you might hear
include:

LEEP
Laser
Cryotherapy
Cone Biopsy
Rarely, a hysterectomy may be recommended

What can I expect after

treatment for CIN?
Estimates of cure range from 73-90% with a
single treatment
The risk for invasive cancer following
treatment is about 1%
Therefore, you still need to have regular
Pap tests
Minimal impact on fertility
May impact on your ability to carry a child
in the future. You should discuss this risk
with your healthcare provider.

What you can do?

Take Control - Protect Yourself
1) Ask your doctor about an appropriate Pap
test screening interval for you
2) Make sure that you get a Pap test at the
recommended time
3) Find out how and when you will learn about
the results of your Pap test
4) Follow-up! Dont assume that no news is
good news
5) Do not smoke

Cervical Cancer Vaccine

What is the cervical

cancer vaccine?
The cervical cancer vaccine (also known as
the Human Papillomavirus or HPV vaccine)
will help prevent cervical cancer by
providing protection from the high-risk
HPV virus types that cause 70% of cervical
cancer
You can significantly decrease your chances
of getting cervical cancer if you get the
vaccine before initial sexual contact
The benefit of the vaccine declines with
increased HPV exposure

Who should get the

vaccine?
The FDA has
recommended the
following groups of
women get
vaccinated:
Girls 1112:
Recommended
Age Group (can be
started as young
as age 9).
Women 1326: the
benefit of the
vaccine may be

Is the cervical cancer

vaccine right for me?

If you are a female between the ages of 11 and 12

the vaccine has proven benefit for you

If you started having sex, you can still get the

vaccine, but the benefit from the vaccine may be
lower because you may have already been exposed
to HPV

The vaccine does not work to eliminate current HPV

infections

The vaccine only prevents certain types of HPV

infection

Early vaccination, regular Pap tests and HPV tests

when recommended by a healthcare provider will
provide you with your best protection against

Older than 26
Cervical cancer vaccines are not FDA
approved for women over the age of
26.
Since there is no proven benefit to
HPV vaccination for women over 26,
your insurance carrier may not pay for
the vaccine.
Regular Pap tests and gynecology
visits will still effectively reduce your
risk for cervical cancer.

What should I expect

at my vaccine
appointment?
You will need a series of three

appointments over 6 months

You will receive a shot, usually in the
upper arm, at each of the three
appointments
Common side effects include:

A sore arm for a day or two

after the vaccine shot
A headache and/or a low grade
fever
You can use over the counter pain and
fever medications if needed
You should not get the vaccine if you

Cervical Cancer

What are the symptoms

of cervical cancer?
Abnormal bleeding
Between periods
With intercourse
After menopause

Unusual vaginal discharge

Other symptoms
Leg pain
Pelvic pain
Bleeding from the rectum or
bladder

have just been

diagnosed with
cervical
cancer?
Discuss treatment options

Conization
Hysterectomy
Radical trachelectomy
Radical hysterectomy
Radiation with chemotherapy

Ask about clinical trials

(Gynecologic Oncology Group)
Other considerations
Preserve your fertility
Preserve your ovaries

Clinical staging of
cervical cancer
IIA1: clinically visible
lesion less than 4 cm*
IIA2: clinically visible
lesion greater than 4 cm*

Source: FIGO Annual Report on The Results of Treatment in Gynaecological Cancer

Journal of Epidemiology and Biostatistics, (2001) vol. 6 no. 1, page 14.
*Mutch D. The new FIGO 2009 staging system for cancers of the vulva, cervix,
endometrium and sarcomas Gynecologic Oncology, (2009) vol. 115, no. 3, pgs 325328

What is a cervical
conization?
Conization:
Removes a
cone-shaped
piece of
tissue
Often allows
for diagnosis
and
treatment
Performed
with local
anesthesia in
the office or
under

Source: TAP Pharmaceuticals,

Female Reproductive Systems.

What is a radical
hysterectomy?
Treatment option for early stage cancer
Not the same as the usual hysterectomy
Surgical removal of the uterus, cervix and
upper vagina with the surrounding tissues
Lymph nodes are removed
Removal of the ovaries is not required

What is a radical
trachelectomy?
A possible treatment option for certain
types of early stage cancer
Surgical removal of the cervix and upper
vagina with the surrounding tissues. The
uterine body (womb) remains inside you.
Lymph nodes are removed
Removal of the ovaries is not required
Not an appropriate treatment option for
everyone with early stage cervical cancer

What is radiation with

chemotherapy (chemoradiation)?

Standard of care for advanced cancer

Treatment requires:

1. External radiation
2. Internal radiation
3. Low dose chemotherapy given at
the same time

Cervical cancer: What is the chance

of survival after treatment?
FIGO Stage

5-Year Survival

Stage I

81-96%

Stage II

65-87%

Stage III

35-50%

Stage IVA

15-20%

Re-establishing Wellness
Restoring wellness is a gradual process
Some women find strength from:

Friends and family

Support groups
Spiritual work
Counseling
Exercise
The challenges and the journey are different
for each woman with cervical cancer

How do I get my friend to have

a Pap test?
Tell her it doesnt hurt
Offer her a ride
Offer help with child care
Help her get an appointment
Help her find the right health care provider
Empower her with information: Tell your friend
about the importance of health prevention

Staging of ca Cervix

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Pap smear

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Colposcopy
Accurate delineation of
suspicious areas for tissue
biopsy.
Suspicious areas appear as
acetowhite areas.

Indications
Abnormal papsmear cytology.
To locate abnormal areas.
To obtain directed biopsy.
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