Download Gynaecological Cancers - Malcolm Padwick MD, FRCOG

Gynaecological
Cancers
Malcolm Padwick MD FRCOG
Cervical Cancer
Cervical Cancer
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1992 national targets set for year 2000
1. Reduce mortality by 20%
2. Achieve 80% smear uptake
1991 targets had already been achieved
Mortality rate had been falling since 1950
at a rate of 1 -2 % per annum
Now 2.3 per 100000
At risk groups
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Young (immature TZ)
Early age of first sexual intercourse
Multiple partners
Smoking
Type of contraception
Screening history
Screening intervals (2004)
Age Group (years)
25
Frequency of
Screening
First invitation
25 - 49
3 yearly
50 - 64
5 yearly
65+
No screen since
age 50 yrs or
recent abnormal
smear
HPV
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1.
2.
3.
HPV subtyping will become available
Concentrate screening on genuinely at
risk women
Allow an increase in the screening
interval
Avoid unnecessary intervention
Referral to Colposcopy
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3 inadequate smears
2 mildly dyskariotic / borderline smears
First moderately or severely dyskariotic
smear
Glandular abnormalities
Suspicion of malignancy
Colposcopy visit
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Information sheets with appointment
Separate clinic waiting area
Changing and washing facilities
Separate consultation area
Comply with NHSCSP appointment
waiting times
Comply with NHSCSP waiting times for
results
Scale of problem
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Watford referrals
1995
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Watford referrals
2003
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228 new patients
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618 new patients
Therefore a follow-up policy
change introduced (NHS)
Colposcopy
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1.
2.
Assess
Biopsy and act on results when available
See and treat
After effects
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3 weeks of diminishing blood stained
discharge
Risk of secondary infection at 1 week
Next period often heavy and painful
Overall post operative pain is minimal
>98% have a clear or better smear result
at 6 months
Cervical cancer
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From colposcopy
General clinic with abnormal bleeding
Acute admission with symptoms of
advanced disease
Staging
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EUA and cystoscopy
Pelvic MRI
Abdominal and chest CT
Normal uterine anatomy
Pre-menopausal
Post-menopausal
Stage IIIB - pelvic sidewall or ureteric
obstruction
MRI signs:
n Same findings as IIB with
involvement of obturator,
piriformis , levators muscles
n Hydroureter
Treatment
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1.
2.
3.
4.
5.
Surgery
Cone biopsy
Radical trachylectomy
Radical hysterectomy
Neoadjuvant chemotherapy combined
with radical surgery
exenteration
Treatment
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Chemo-radiation as a primary treatment
Radiotherapy as post operative treatment
for poor prognostic disease
Chemotherapy or radiotherapy for
palliation
consequences
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1.
2.
3.
4.
Surgery
Acute complications
Fistula
Bladder dysfunction
Body image
General improvement with time.
consequences
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1.
2.
3.
4.
5.
Chemoradiation
Alopecia
Radiation burns
Vaginal stenosis and inflammation
Cystitis and colitis
Fistula bowel and bladder
Side effects tend to get worse with time.
The future
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Improved prevention
Less invasive treatment for pre-cancer
vaccination
outcome
Stage
5 year survival
I
II
III
IV
80%
60%
20%
5%
Malcolm Padwick MD FRCOG
Gynaecologist
West Herts NHS Trust
Ovarian Cancer
General impression
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Middle class disease
Effects older population
Silent killer
One of the diseases GPs fear missing the
most
Mortality 12 per 100000
At risk groups
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Post menopausal
Nulliparous
Family history (including breast cancer)
Contraceptive usage
Endometriosis
Environmental
Screening
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Genetic - BRCA 1 and 2 mutations
USS and CA125 ?????
Prophylactic oopherectomy after 40 years
+/- HRT
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General population
USS and CA125 ?????
Research projects only
presentation
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Abdominal distension
Abnormal PV bleeding
Abdominal discomfort
Dyspepsia
Bowel symptoms
From physicians and general surgeons
Investigations
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CA125
USS
laparoscopy
CT
MRI
Typical peritoneal nodules of
ovarian cancer
Management
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MDT
Surgery +/- chemotherapy
Staging and randomization into interval
debulking study
Interval debulking
Pregnancy associated mass
Peritoneal nodules of ovarian cancer
before and after carboplatin
Follow-up
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CA125
CT
Relapse chemotherapy
Relapse surgery
Outcome
Stage
5 Year survival
I
II
III
IV
90%
70%
25%
5%
Future
?
Endometrial Cancer
Malcolm Padwick
Endometrial Cancer
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65 of all cancers in women
postmenopausal
obese (hypertensive, diabetic)
HRT
tamoxifen
Symptoms
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PMB
IMB
PCB
Pap smear
Pain
Weight loss, bowel and bladder changes
Abnormal bleeding on HRT
Managment
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Refer to the “rapid access clinic”
Use cancer pro forma
Investigations
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Pelvic USS
If endometrial signal > 4mm for
endometrial biopsy -- either pippelle or
hysteroscopy and currettage
High risk symptoms go straight to H & C