Cervical Cancer Screening· Evaluation· Treatment

1. Cervical CancerScreening· Evaluation· Treatment

2. About this Presentation This presentation is intended to help women take an active role in their health care. It does not replace the judgment of a health care professional in diagnosing and treating disease.

3. GCF Mission Statement The mission of the Gynecologic Cancer Foundation (GCF) is to ensure public awareness of gynecologic cancer prevention, early diagnosis and proper treatment. In addition the Foundation supports research and training related to gynecologic cancers. GCF advances this mission by increasing public and private funds that aid in the development and implementation of programs to meet these goals. GCF gratefully acknowledges the National Cervical Cancer Coalition (NCCC) for their support of this educational presentation. For more information on NCCC, call (800) 685-5531 or visit the Web site at www.nccc-online.org.

4. Information Hotline: (800) 444-4441 • A list of specially trained gynecologic oncologists practicing in your local area can be received by phone, fax or mail • A directory of all GCF members practicing in the U.S. can also be mailed upon request • Free educational brochures on gynecologic health

5. Women’s Cancer Network: www.wcn.org • Confidential gynecologic (ovarian, endometrial, cervical) and breast cancer risk assessment • Comprehensive women’s cancer information including gynecologic, breast, lung and colon cancers • Links to other sources of cancer information

6. Cervical Cancer Screening and Prevention

7. New cancer diagnoses in the U.S. 2003 Statistics: • Breast 211,300 • Uterus (womb) 40,100 • Ovary 25,400 • Cervix 12,200 • Vulva 4,000 Source: American Cancer Society.

8. What is cervical cancer? • It is a cancer of the female reproductive tract • It is the most common cause of cancer death in the world where Pap tests are not available • It is the easiest gynecologic cancer to prevent through screening

9. What is the female reproductive tract? • Vulva • Vagina • Cervix • Uterus • Fallopian tubes • Ovaries

10. What is the cervix? • Opening of the uterus (womb) into the vagina • Two cell types present (squamous and glandular) • Cervical cancers tend to occur where the two cell types meet Source: TAP Pharmaceuticals, “Female Reproductive Systems.”

11. How common is cervical cancer? • 500,000 women worldwide die of cervical cancer annually • 50-60 million women in the U.S. have a Pap test each year • 3-5 million women in the U.S. have an abnormal result • 12,200 new cervical cancers diagnosed in the U.S. per year • 4,100 deaths from cervical cancer in the U.S. per year Most cervical cancer can be prevented

12. What causes cervical cancer? The central cause of cervical cancer is human papillomavirus or HPV: • HPV is sexually transmitted • The HPV detected today could have been acquired years ago • There are many different types of HPV • Low-risk types can cause warts • High-risk types can cause precancer and cancer of the cervix

13. If I have HPV, does it mean I will get cancer? • NO! • In most cases HPV goes away • Only women with persistent HPV (where the virus does not go away) are at risk for cervical cancer

14. How common is HPV? • Most men and women who have had sex have been exposed to HPV • More than 75% of sexually active women tested have been exposed to HPV by age 18-22

15. Who is at risk? • Women who have ever had sex • Women who have had more than one partner • Women whose partner (s) has had more than one sexual partner • Women with other sexually transmitted diseases

16. Who is at risk? • Women who do not have Paptests • Women with immune problems • Steroid medications • Transplanted organs • Chemotherapy • HIV • Women who smoke

17. How do I lower my risk? • Delay onset of sexual activity • Know your sexual partner • Do not smoke • Maintain a healthy diet and lifestyle • Practice safe sex Get your Pap test

18. What is a Pap test? • A test which collects cells from the surface of the cervix and looks for any abnormal cells • Abnormal cells can be treated before cervical cancer develops • When cancer is detected early, it is easier to treat

19. What a Pap test is NOT! • A pelvic exam • A test for ovarian or uterine cancer • A biopsy

20. When do I need my first Pap test? • Three years after the onset of sexual intercourse • No later than age 21

21. How often do I need a Pap test? • Every year until age 30 • After age 30, if you have only had normal results, you may have them every two to three years after discussion with your physician and evaluation of your risk factors

22. I feel fine, so why do I need a Pap test? • A Pap test can find treatable changes of the cervix (precancer) before you have a symptom or notice a problem • Once a problem is symptomatic, it is harder to treat

23. Why do I need to keep getting tested? • The test is not perfect • Changes (abnormalities) may occur since the last test • It may take many years for changes to develop or be detected • Your risk changes if you have new partners

24. What is the best time to have a Pap test? • Schedule your Pap when you are not having a menstrual period • It is best to abstain from intercourse and avoid use of tampons or douches for two days before your Pap test

25. What should I expect when I havea Pap test? • Feet are placed in stirrups (foot holders) • A speculum (thin duck-billed instrument) is inserted into vagina to see the cervix • You may have brief discomfort which is usually mild • You may have some spotting afterward

26. How do I find out about my Pap test results? • You may ask to have a copy mailed to you • You may call for your results • If you have an abnormal result, it is extremely important to follow-up for the recommended testing • Even after a normal Pap test, it is still important to report any symptoms of abnormal vaginal bleeding, discharge or pain to your doctor and call to be seen right away

27. Do I need a Pap test if I had a hysterectomy? • If you had treatment for precancer or cancer of the cervix, you may need a Pap test • If the cervix was left in place at the time of your hysterectomy, you will still need Pap tests • Preventive health care is still important even if you do not need a Pap test

28. Is there an age when I can stop having Pap tests? The American Cancer Society recommends that screening stop at age 70, if three or more recent tests are normal, and there have been no abnormal results in the last 10 years.

29. What is new in screening and prevention? • Liquid cytology-thin layer cytology • Combination of HPV test and Pap is now available for women 30 years of age and older • Pap test computer reviews • Vaccines for HPV currently being tested

30. Evaluation of the Abnormal Pap Test and Treatment of Precancer

31. Abnormal Pap test – How common is it? 12,200 cancers 300,000 HSIL 1.25 million LSIL 2-3 million ASC 50-60 million women screened

32. What is an HPV test? • A test sometimes used to determine if you need further evaluation • Cells are collected just like a Pap test • It checks for high-risk HPV

33. What happens if I have an abnormal Pap test? • ASC-US management options: • HPV testing • Repeat Pap • Colposcopy • ASC-H, LSIL, HSIL, AGC, AIS, cancer • Colposcopy • Possibly endometrial biopsy for AGC • AIS / cancer: referral to gynecologic oncologist

34. What is a colposcopy? Colposcopy: • Use of a magnifying instrument • Application of a vinegar-like solution onto the cervix • See abnormalities that can’t be seen with the naked eye • Feels like getting a Pap test, but lasts longer Source: This is a copyrighted image of the California Family Health Council, Inc. and may not be reproduced in any way without the expressed written permission of the California Family Health Council. California Department of Health Services "What You Should Know if your Pap Test is Abnormal"- Your Colposcopy Exam, Donna Bell Sanders (Education Programs Associates 1995; Campbell, CA).

35. What is a cervical biopsy? Biopsy: • Removal of a small piece of tissue from the cervix • May feel like getting a Pap test or like a menstrual cramp that lasts a few seconds Source: TAP Pharmaceuticals, “Female Reproductive Systems.” Source: A. DeCherney and M. Pernoll, Current Obstetric and Gynecologic Diagnosis and Treatment (The McGraw-Hill Companies, Inc.) 586.

36. What does the biopsy result mean? • Mildly abnormal (CIN I) • observation preferred • More abnormal (CIN II) • treatment • Precancer (CIN III) • treatment • Cancer • Gynecologic oncology consultation

37. What are the treatment options for CIN? • LEEP • Laser • Cryotherapy • Cone Biopsy • In special circumstances a hysterectomy may be recommended

38. What can I expect after treatment for CIN? • Estimates of cure range from 73-90% with a single treatment • The risk for invasive cancer following treatment is about 1% • Therefore, you still need to have regular Pap tests • Minimal, if any, impact on fertility

39. What you can do? Take Control - Protect Yourself 1) Ask your doctor about an appropriate Pap test screening interval for you 2) Make sure that you get a Pap test at the recommended time 3) Find out how and when you will learn about the results of your Pap test 4) Follow-up! Don’t assume that no news is good news 5) Do not smoke

40. Cervical Cancer

41. What are the symptoms of cervical cancer? • Abnormal bleeding • Between periods • With intercourse • After menopause • Unusual vaginal discharge • Other symptoms • Leg pain • Pelvic pain • Bleeding from the rectum or bladder • Some women have no symptoms

42. What should I do if I have just been diagnosed with cervical cancer? • Find a gynecologic oncologist • Call 1-800-444-4441 • Discuss treatment options • Conization • Hysterectomy • Radical hysterectomy • Radiation with chemotherapy • Ask about clinical trials (Gynecologic Oncology Group) • Other considerations • Preserve your fertility • Preserve your ovaries

43. Clinical staging of cervical cancer Source: “FIGO Annual Report on The Results of Treatment in Gynaecological Cancer” Journal of Epidemiology and Biostatistics, (2001) vol. 6 no. 1, page 14.

44. What is a cervical conization? • Conization: • Removes a cone-shaped piece of tissue • Often allows for diagnosis and treatment • Performed with local anesthesia in the office or under general anesthesia in the operating room Source: TAP Pharmaceuticals, “Female Reproductive Systems.”

45. What is a radical hysterectomy? • Treatment option for early stage cancer • Not the same as the usual hysterectomy • Surgical removal of the uterus, cervix and upper vagina with the surrounding tissues • Lymph nodes are removed • Removal of the ovaries is not required

46. What is radiation with chemotherapy (chemoradiation)? • Standard of care for advanced cancer • Treatment requires: • External radiation • Internal radiation • Low dose chemotherapy given at the same time

47. Cervical cancer: What is the chance of survival after treatment?

48. Re-establishing Wellness • Restoring wellness is a gradual process • Some women find strength from: • Friends and family • Support groups • Spiritual work • Counseling • Exercise • The challenges and the journey are different for each woman with cervical cancer

49. How do I get my friends to have a Pap test? • Tell her it doesn’t hurt • Offer her a ride • Offer help with child care • Help her get an appointment • Help her find the right health care provider • Empower her with information: Tell your friend about the importance of health prevention

50. Bobbie Gostout, M.D., Editor Wendy Brewster, M.D. Karen Carlson Thomas Cox, M.D. Juan Felix, M.D. Hollis Forster Christine Holschneider, M.D. Beth Karlan, M.D. Alan Kaye Hershel Lawson, M.D. Suzy Lockwood, R.N., M.S.N., Ph.D. Saralyn Mark, M.D. F.J. Montz, M.D., K.M. (1955-2002) Mitchell Morris, M.D. Karl Podratz, M.D., Ph.D. Karen Riordan Debbie Saslow, Ph.D. Evelyn Schulman Alice Spinelli, M.S.N., A.R.N.P. Joan Walker, M.D. Leslie Walton, M.D. Thomas Wright, Jr., M.D. Cervical Cancer Presentation ParticipantsGCF gratefully acknowledges the following individuals who contributed to this educational presentation: