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Gynaecological Cancers

Gynaecological Cancers. Malcolm Padwick MD FRCOG. Cervical Cancer. Cervical Cancer. 1992 national targets set for year 2000 1. Reduce mortality by 20% 2. Achieve 80% smear uptake 1991 targets had already been achieved

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Gynaecological Cancers

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  1. Gynaecological Cancers Malcolm Padwick MD FRCOG

  2. Cervical Cancer

  3. Cervical Cancer • 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

  4. At risk groups • Young (immature TZ) • Early age of first sexual intercourse • Multiple partners • Smoking • Type of contraception • Screening history

  5. Screening intervals (2004)

  6. HPV • HPV subtyping will become available • Concentrate screening on genuinely at risk women • Allow an increase in the screening interval • Avoid unnecessary intervention

  7. Referral to Colposcopy • 3 inadequate smears • 2 mildly dyskariotic / borderline smears • First moderately or severely dyskariotic smear • Glandular abnormalities • Suspicion of malignancy

  8. Colposcopy visit • 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

  9. Watford referrals 1995 228 new patients Watford referrals 2003 618 new patients Scale of problem Therefore a follow-up policy change introduced (NHS)

  10. Colposcopy • Assess • Biopsy and act on results when available • See and treat

  11. After effects • 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

  12. Cervical cancer • From colposcopy • General clinic with abnormal bleeding • Acute admission with symptoms of advanced disease

  13. Staging • EUA and cystoscopy • Pelvic MRI • Abdominal and chest CT

  14. Treatment • Surgery • Cone biopsy • Radical trachylectomy • Radical hysterectomy • Neoadjuvant chemotherapy combined with radical surgery • exenteration

  15. Treatment • Chemo-radiation as a primary treatment • Radiotherapy as post operative treatment for poor prognostic disease • Chemotherapy or radiotherapy for palliation

  16. consequences • Surgery • Acute complications • Fistula • Bladder dysfunction • Body image General improvement with time.

  17. consequences • Chemoradiation • Alopecia • Radiation burns • Vaginal stenosis and inflammation • Cystitis and colitis • Fistula bowel and bladder Side effects tend to get worse with time.

  18. The future • Improved prevention • Less invasive treatment for pre-cancer • vaccination

  19. Stage I II III IV 5 year survival 80% 60% 20% 5% outcome

  20. Malcolm Padwick MD FRCOG Gynaecologist West Herts NHS Trust

  21. Ovarian Cancer

  22. General impression • Middle class disease • Effects older population • Silent killer • One of the diseases GPs fear missing the most Mortality 12 per 100000

  23. At risk groups • Post menopausal • Nulliparous • Family history (including breast cancer) • Contraceptive usage • Endometriosis • Environmental

  24. Screening • Genetic - BRCA 1 and 2 mutations USS and CA125 ????? Prophylactic oopherectomy after 40 years +/- HRT • General population USS and CA125 ????? Research projects only

  25. presentation • Abdominal distension • Abnormal PV bleeding • Abdominal discomfort • Dyspepsia • Bowel symptoms • From physicians and general surgeons

  26. Investigations • CA125 • USS • laparoscopy • CT • MRI

  27. Management • MDT • Surgery +/- chemotherapy • Staging and randomization into interval debulking study • Interval debulking • Pregnancy associated mass

  28. Follow-up • CA125 • CT • Relapse chemotherapy • Relapse surgery

  29. Stage I II III IV 5 Year survival 90% 70% 25% 5% Outcome

  30. Future ?

  31. Endometrial Cancer Malcolm Padwick

  32. Endometrial Cancer • 65 of all cancers in women • postmenopausal • obese (hypertensive, diabetic) • HRT • tamoxifen

  33. Symptoms • PMB • IMB • PCB • Pap smear • Pain • Weight loss, bowel and bladder changes • Abnormal bleeding on HRT

  34. Managment • Refer to the “rapid access clinic” • Use cancer pro forma

  35. Investigations • Pelvic USS • If endometrial signal > 4mm for endometrial biopsy -- either pippelle or hysteroscopy and currettage • High risk symptoms go straight to H & C

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