WHAT IS CERVICAL CANCER? Presented by Dr. Sylvia Deganus

WHAT IS CERVICAL CANCER? Presented by Dr. Sylvia Deganus

The Presentation What is Cancer What and where is the Cervix What causes cervical Cancer How serious is the problem of cervical cancer in Ghana? How do we address the problem (Next presentation) Questions

WHAT IS CANCER? Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body (including the cervix). Normal cells grow and divide to form new cells as the body needs them. When normal cells grow old or get damaged, they die, and new cells take their place. NORMALLY, CELLS, THE BOBY BULDING BLOCKS, GROW IN AN ORGANISED FASHION

WHAT IS CANCER? Sometimes, this process of cell growth goes wrong. New cells form when the body does not need them, and old or damaged cells do not die as they should. The buildup of extra cells often forms a mass of tissue called a growth or tumor. CANCER IS SAID TO OCCUR WHEN: Cancer is when cells in a part of the body begin to multiply in an uncontrolled and haphazardly manner. They invade neighboring and far tissues causing damage to them and affecting their function

Normal versus Cancer Normal, well Organized cells Unhealthy haphazardly growing and invading cancer cells

CANCER CAN AFFECT ANY PART OF THE BODY Cancer can occur in any part of the body: Breast, Brain, Bone, Blood, Cervix etc. and can spread from the initial site to other parts of the body.

What and Where is the CERVIX? It can be felt at the top part of the vagina It feels firm like your nose It is the lower part of the womb. And is the opening or entrance into the womb

THE FEMALE REPRODUCTIVE ORGANS 2 R OVARY FALLOPIAN TUBES UTERUS CERVIX L OVARY VAGINA VAGINA

So what is Cervical Cancer or Cancer of the cervix? It is when the cells that make up the cervix begin to grow haphazardly in an uncontolled fashion and spreads to other parts of the womans body It starts small like a rash and grows to become a large and extensive sore destroying the cervix, the vagina and neighbouring organs like bladder etc.

CANCER OF THE CERVIX: Abnormal, uncontrolled growth of cervical tissue UTERUS CANCER TISSUE DESTROYING CERVIX WITH BLEEDING

WHO TENDS TO GET (AT RISK) CERVICAL CANCER? Women 40-60 years Women with multiple sexual partners Women with the high risk human papilloma virus infection Women with relatives who have had cervical cancer Women with high parity (many childbirths)

CANCER OF CERVIX WARNING SIGNS! NO SIGNS OR SYMPTOMS IN EARLY STAGE OF DISEASE WHEN DISEASE IS ADVANCED THEN PROVOKED BLEEDING EG. AFTER SEX or WASHING IRREGULAR INTERMENSTRUAL BLEEDING CONTINOUS OFFENSIVE BLOOD STAINED DISCHARGE BLEEDING AFTER MENOPAUSE

WHAT CAUSES CERVICAL CANCER? Human Papilloma Virus (HPV) prevalence in more than 1,000 samples of invasive Cervical Cancer from 25 countries: 99.8% Cancer causing strains (Oncogenic types No.16,18, 33) are present in 99% of cervical cancers

HPV Infections: Natural history Ubiquitous in humans: - skin and mucosal lining Mucosal HPVs are sexually transmitted The most frequent STI High detection in sexually active men and women. Not detected in virgins.

GENITAL HPV INFECTIONS: From Warts to Cancer Slide : Courtesy Dr Effah

What Causes Cervical Cancer We Now know it is associated with Human Papilloma Virus (HPV) infection It is a Sexually transmitted virus The oncogenic strains trigger abnormal growth of cervical cells The disease has long latency, slow progression 17

HPV Infections are Very Common HPV infection is easily transmitted, usually starting soon after sexual debut 1,2 A Study in Ghana at KBTH in 2008 found 10.7% prevalence Up to 80% of sexually active women will be infected with HPV at some point in their lifetime 3,4,5 Oncogenic HPV types (16,18,33,45) have been found in up to 75% of HPV infections 6,7 1. McIntosh N. Human papillomavirus and cervical cancer. JHPIEGO 2000; 2. Baseman JG, Koutsky LA J Clin Virol 2005;32S: S16-S24; 3. Burk RD Hosp Pract 1999;34: 103-111; 4. Bosch FX et al. J Clin Pathol 2002; 55: 244 65; 5. Koutsky L. Am J Med 1997;102(5A) :3-8; 6. Cuschieri KS et al. J Clin Pathol 2004;57: 68-72; 7. Peto J, et al. Br J Cancer 2004; 91: 942-953

Natural history of cervical cancer Months 1-15 Years Decades Sexual debut Normal epithelium HPV infection LSIL CIN1 70-90% CIN2 HSIL CIN3/CIS Invasive cancer Primary prevention Screening 20% Treatment PERSISTENT INFECTION CIN = Cervical Intraepithelial Neoplasia SIL= Squamous Intraepithelial Lesion

Time Natural History From Infection to Cervical Cancer Months Years Normal epithelium HPV infection; koilocitosis CIN I CIN II CIN III Invasive Carcinoma Low grade squamous intraepithelial lesion (ASCUS/LSIL) High grade squamous intraepithelial lesion (HSIL) From incident to persistent HPV infection Spontaneous regression Screening Treatment

How Serious is the Problem of Cervical Cancer?

The most frequent cancers in women AFRICAN CONTINENT Incidence Africa Continent Mortality Africa Continent Cervix uteri 29.3 Cervix uteri 23.1 Breast 23.4 Breast 16.2 Liver 6.2 Liver 6.2 Stomach 4.9 Stomach 4.6 Kaposi sarcoma 4.6 Kaposi sarcoma 4.3 Ovary etc. 4.3 Colon and rectum 3.7 Colon and rectum 4.2 Oesophagus 3.2 Non-Hodgkin lymphoma 3.9 Non-Hodgkin lymphoma 3.0 Oesophagus 3.4 Ovary etc. 3.0 Corpus uteri 2.7 Bladder 2.4 0 10 20 30 40 50 0 10 20 30 40 Globocan 2002 Age-standardized INCIDENCE rates (all ages) Age-standardized MORTALITY rates (all ages)

The Problem in Ghana Ghana has 6.57 Million women of ages 15+ Crude incidence 21.5 per 100,000 women per year Estimates are 3038 cases of CA CX each year of whom 2006 will die It is the most frequent Cancer in women Data indicate that 57.8% of all Gynaecological cancer is Cervical

FIG. 3 The peak in females occurs from 35 to 54 years The peak age in males occurs after 64 years Due mainly to breast and cervical cancers in females, which occur largely between 35 and 54 and prostate in males, which is a disease of the elderly. (Courtsey Prof. E. K. Wiredu)

GYNAECOLOGICAL & BREAST CANCERS SEEN AT THE RADIO RX CENTER KBTH ( 1997-2004) 0% 0% 0% 1% 2% 28% 28% 38% CA Cx Breast EndoMT Ovary Vulva Vagina Placenta Uterus All Other CA 3%

GYNECOLOGICAL CANCERS SEEN AT THE O & G UNIT Korle Bu Teaching Hospital ( 52 MONTH PERIOD) 2.8 % OF ADMISSIONS TO Gynae unit Mean Mean Proportion Age Parity Cervical CA 57.8% 52 5.8 Ovarian CA 25.3% 46 3.5 Endometrial CA 7.43% 56 5.4 Choriocacinoma 6.93% Vulva 2.21% Courtesy Dr. K. Nkyerkyer

Cervical Cancer cases in Komfo Anokye Teaching Hospital 2003-2011 (Courtesy Dr Baffour Awuah) CA Cervix: 28.7% of all Cancers Seen (1290 out of 4497) The Leading CA in females Cervix = 1290 cases (40%) Peak Age : 40-50 years Present with late Disease : Stages 2-4

Is Cervical Cancer Is Preventable? Answer=YES Prevent transmission of HPV virus Reduce risk factors, such as smoking, early onset sexual activity Detect abnormalities on cervix early Treat precancerous lesions to prevent progression to cancer 29

Cervical Cancer Prevention Primary prevention Education to reduce high-risk sexual behavior HPV Vaccine Secondary prevention Identify and treat precancerous lesions before they progress to cervical cancer Tertiary Prevention Identify and treat early cancer while the chance of cure is still good (prevents cervical cancer death)

PRIMARY PREVENTION Avoiding HPV: risk factors Positive risk factors: Early age at first sexual intercourse. Number of sexual partners. Contacts with high-risk men Protective risk factors: Consistent condom use (Winer et al. NEJM 2006) Male circumcision (Castellsagué et al. NEJM 2002)

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