Gynaecological Gynaecological CancersCancers

Malcolm Padwick MD FRCOGMalcolm Padwick MD FRCOG

Cervical CancerCervical Cancer

Cervical CancerCervical Cancer

• 1992 national targets set for year 1992 national targets set for year 20002000

1. Reduce mortality by 20%1. Reduce mortality by 20%

2. Achieve 80% smear uptake2. Achieve 80% smear uptake• 1991 targets had already been 1991 targets had already been

achievedachieved• Mortality rate had been falling since Mortality rate had been falling since

1950 at a rate of 1 -2 % per annum1950 at a rate of 1 -2 % per annum• Now 2.3 per 100000 Now 2.3 per 100000

At risk groupsAt risk groups

Young (immature TZ)Young (immature TZ) Early age of first sexual intercourseEarly age of first sexual intercourse Multiple partnersMultiple partners SmokingSmoking Type of contraceptionType of contraception Screening historyScreening history

Screening intervals Screening intervals (2004)(2004)

Age Group Age Group (years)(years)

Frequency of Frequency of Screening Screening

2525 First invitationFirst invitation

25 - 4925 - 49 3 yearly3 yearly

50 - 6450 - 64 5 yearly5 yearly

65+65+ No screen since No screen since age 50 yrs or age 50 yrs or recent recent abnormal smearabnormal smear

HPVHPV

HPV subtyping will become HPV subtyping will become availableavailable

1.1. Concentrate screening on Concentrate screening on genuinely at risk womengenuinely at risk women

2.2. Allow an increase in the screening Allow an increase in the screening intervalinterval

3.3. Avoid unnecessary intervention Avoid unnecessary intervention

Referral to ColposcopyReferral to Colposcopy

3 inadequate smears3 inadequate smears 2 mildly dyskariotic / borderline 2 mildly dyskariotic / borderline

smearssmears First moderately or severely First moderately or severely

dyskariotic smeardyskariotic smear Glandular abnormalitiesGlandular abnormalities Suspicion of malignancySuspicion of malignancy

Colposcopy visitColposcopy visit

Information sheets with appointmentInformation sheets with appointment Separate clinic waiting areaSeparate clinic waiting area Changing and washing facilitiesChanging and washing facilities Separate consultation areaSeparate consultation area Comply with NHSCSP appointment Comply with NHSCSP appointment

waiting timeswaiting times Comply with NHSCSP waiting times Comply with NHSCSP waiting times

for resultsfor results

Scale of problemScale of problem

Watford referrals Watford referrals 19951995

228 new patients228 new patients

Watford referrals Watford referrals 20032003

618 new patients618 new patients

Therefore a follow-up policy change introduced (NHS)

ColposcopyColposcopy

Assess Assess

1.1. Biopsy and act on results when Biopsy and act on results when availableavailable

2.2. See and treatSee and treat

After effectsAfter effects

3 weeks of diminishing blood stained 3 weeks of diminishing blood stained dischargedischarge

Risk of secondary infection at 1 weekRisk of secondary infection at 1 week Next period often heavy and painfulNext period often heavy and painful Overall post operative pain is minimalOverall post operative pain is minimal >98% have a clear or better smear >98% have a clear or better smear

result at 6 monthsresult at 6 months

Cervical cancerCervical cancer

From colposcopyFrom colposcopy General clinic with abnormal General clinic with abnormal

bleedingbleeding Acute admission with symptoms of Acute admission with symptoms of

advanced diseaseadvanced disease

StagingStaging

EUA and cystoscopyEUA and cystoscopy Pelvic MRIPelvic MRI Abdominal and chest CTAbdominal and chest CT

Normal uterine anatomyNormal uterine anatomy

Pre-menopausalPre-menopausal Post-menopausalPost-menopausal

Stage IIIB - Stage IIIB - pelvic sidewall orpelvic sidewall or ureteric uretericobstructionobstruction

MRI signs:MRI signs:nn Same findings as IIB withSame findings as IIB with

involvement of obturator,involvement of obturator,piriformispiriformis, levators muscles, levators muscles

nn HydroureterHydroureter

TreatmentTreatment

SurgerySurgery

1.1. Cone biopsyCone biopsy

2.2. Radical trachylectomyRadical trachylectomy

3.3. Radical hysterectomyRadical hysterectomy

4.4. Neoadjuvant chemotherapy Neoadjuvant chemotherapy combined with radical surgerycombined with radical surgery

5.5. exenterationexenteration

TreatmentTreatment

Chemo-radiation as a primary Chemo-radiation as a primary treatmenttreatment

Radiotherapy as post operative Radiotherapy as post operative treatment for poor prognostic treatment for poor prognostic diseasedisease

Chemotherapy or radiotherapy for Chemotherapy or radiotherapy for palliationpalliation

consequencesconsequences

SurgerySurgery

1.1. Acute complicationsAcute complications

2.2. FistulaFistula

3.3. Bladder dysfunctionBladder dysfunction

4.4. Body imageBody image

General improvement with time.General improvement with time.

consequencesconsequences ChemoradiationChemoradiation1.1. AlopeciaAlopecia2.2. Radiation burnsRadiation burns3.3. Vaginal stenosis and inflammationVaginal stenosis and inflammation4.4. Cystitis and colitisCystitis and colitis5.5. Fistula bowel and bladderFistula bowel and bladder

Side effects tend to get worse with time.Side effects tend to get worse with time.

The futureThe future

Improved preventionImproved prevention Less invasive treatment for pre-Less invasive treatment for pre-

cancercancer vaccinationvaccination

outcomeoutcome

Stage Stage

II

IIII

IIIIII

IVIV

5 year survival5 year survival

80%80%

60%60%

20%20%

5%5%

Malcolm Padwick MD Malcolm Padwick MD FRCOGFRCOG

Gynaecologist Gynaecologist

West Herts NHS TrustWest Herts NHS Trust

Ovarian CancerOvarian Cancer

General impressionGeneral impression

Middle class diseaseMiddle class disease Effects older populationEffects older population Silent killerSilent killer One of the diseases GPs fear missing One of the diseases GPs fear missing

the mostthe most

Mortality 12 per 100000

At risk groupsAt risk groups

Post menopausalPost menopausal NulliparousNulliparous Family history (including breast Family history (including breast

cancer)cancer) Contraceptive usageContraceptive usage EndometriosisEndometriosis EnvironmentalEnvironmental

Screening Screening

• Genetic - BRCA 1 and 2 mutationsGenetic - BRCA 1 and 2 mutationsUSS and CA125 ?????USS and CA125 ?????

Prophylactic oopherectomy after 40 years Prophylactic oopherectomy after 40 years

+/- HRT+/- HRT• General populationGeneral population

USS and CA125 ?????USS and CA125 ?????

Research projects onlyResearch projects only

presentationpresentation

Abdominal distensionAbdominal distension Abnormal PV bleedingAbnormal PV bleeding Abdominal discomfortAbdominal discomfort DyspepsiaDyspepsia Bowel symptomsBowel symptoms From physicians and general From physicians and general

surgeonssurgeons

InvestigationsInvestigations

CA125CA125 USSUSS laparoscopylaparoscopy CTCT MRIMRI

Typical peritoneal nodules ofovarian cancer

ManagementManagement

MDTMDT Surgery +/- chemotherapySurgery +/- chemotherapy Staging and randomization into Staging and randomization into

interval debulking studyinterval debulking study Interval debulkingInterval debulking Pregnancy associated massPregnancy associated mass

Peritoneal nodules of ovarian cancerbefore and after carboplatin

Follow-upFollow-up

CA125CA125 CTCT Relapse chemotherapyRelapse chemotherapy Relapse surgery Relapse surgery

OutcomeOutcome

StageStage

II

IIII

IIIIII

IVIV

5 Year survival5 Year survival

90%90%

70%70%

25%25%

5%5%

FutureFuture

??

Endometrial Endometrial CancerCancer

Malcolm PadwickMalcolm Padwick

Endometrial CancerEndometrial Cancer

65 of all cancers in women65 of all cancers in women postmenopausal postmenopausal obese (hypertensive, diabetic)obese (hypertensive, diabetic) HRTHRT tamoxifentamoxifen

SymptomsSymptoms

PMBPMB IMBIMB PCBPCB Pap smearPap smear PainPain Weight loss, bowel and bladder Weight loss, bowel and bladder

changeschanges Abnormal bleeding on HRTAbnormal bleeding on HRT

ManagmentManagment

Refer to the “rapid access clinic”Refer to the “rapid access clinic” Use cancer pro formaUse cancer pro forma

InvestigationsInvestigations

Pelvic USSPelvic USS If endometrial signal > 4mm for If endometrial signal > 4mm for

endometrial biopsy -- either pippelle endometrial biopsy -- either pippelle or hysteroscopy and currettageor hysteroscopy and currettage

High risk symptoms go straight to H High risk symptoms go straight to H & C& C