Cervical Cancer
Can we prevent it?
Dr Paul Byrne MD FRCOG FRCPI
Department of Obstetrics & Gynaecology
Rotunda Hospital & Beaumont Hospital
Overview
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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
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Commonest cancer in women in developing countries
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The second most common cancer in women worldwide
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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
% Cancer Deaths
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
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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
Cervical Intraepithelial Neoplasia (CIN)
SIL
Squamous Intraepithilial lesion
Cervical Neoplasia - A sexually transmitted disease
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Cervical cancer
 Rarely seen in women who have never had sexual intercourse
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Risk of developing cervical cancer is related to:
 Early age at first intercourse
 Number of partners
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HPV is sexually transmitted
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Cervical neoplasia occurs when the cervical transformation zone is
exposed to HPV
Human Papillomavirus (HPV)
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A double stranded DNA virus that infects squamous epithelia where it causes
warts and tumours
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100 different types of HPV
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HPV types 6 and 11 cause approximately 90% of genital warts
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Genital warts are highly contagious - two-thirds of people who have sexual
contact with an infected partner will develop warts
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HPV types 16 and 18 cause approximately 70% of cervical cancers
• Cervical
cytology
• CervicalCheck
screening
programme
Early Diagnosis
• Vaccination
Secondary prevention
Primary prevention
Prevention of deaths from cervical cancer
• Down staging
of cancers at
diagnosis
• Agreed
assessment
and referral for
women with
symptoms
Screening for Cervical Neoplasia
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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
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Low power magnification of the cervix
Assess the transformation zone
Detect CIN
Treat CIN
Abnormal Transformation zone
CIN3
Normal transformation zone
LLETZ procedure
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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
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Stage 1b & 2A
 Radical Hysterectomy
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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.
Exam Question…………………
Cervical Cancera preventable disease.
Discuss.