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SCREENING IN GYNECOLOGICAL
CANCER
Taravat Fakheri
OB/GYN
KUMS
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26% Lung and bronchus
15% Breast26%
Lung and bronchus
15% Breast
9%
Colon and rectum
7%
Pancreas
5%
Ovary
4%
Non-Hodgkin
lymphoma
3%
Leukemia
3%
Uterine corpus
2%
Liver
2%
Brain
9%
Colon and rectum
7%
Pancreas
5%
Ovary
4%
Non-Hodgkin
lymphoma
3%
Leukemia
3%
Uterine corpus
2%
Liver
2%
Brain
Cancer prevention
• Primary Prevention = Identification &
modification of risk factors.
• Secondary prevention=Detection at an earlier
more treatable stage.
• Tertiary prevention=Effective treatment of
clinical disease.
Primary Prevention
CA Cx
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1=Barrier method
2=Decrease Tobacco
3=Diet high folate Vit B,B carotene.
4=HPV vaccine.
Primary Prevention
CA Endo
• 1=Ideal body weight.
• 2=Low fat diet
• 3=Avoid unopposed estrogen in menaupose.
Primary Prevention
CA Ovary
• 1=Use OC.
• 2=Avoid talk.
• 3=in gene carriers salpingo ophorectomy.
Secondary Prevention
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Detect disease at more curable stage
In suitable disease & suitable screening test.
suitable disease=Serious consequence
Have preclinical phase.
Preclinical long enough.
suitable screening test
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Simple
Acceptable.
Low cost
High validity
Natural history of low-grade HPV
cervical lesion
• Cervical HPV is very common, related to
sexual behavior
• High spontaneous remission rate
• lower remission rate in CIN
• LSIL progress to HSIL in 70% in 10 yrs
HPV DNA Testing
• Together with Pap Smear every 2 year is
beneficial cost benefit.
• Sensitivity =100%
Ovarian Tumors
• High mortality due to late diagnosis
• 75% of ca ovary at diagnosis were at late stage
with a 28% 5 yr survival
• Stage I ca ovary has 95% 5 yr survival
Symptoms
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asymptomatic
Lower abdominal pain/pressure
mass
Abdominal enlargement
Vaginal bleeding
Urinary/bowel symptoms
Risk factors
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1) majority has no risk factor
2) family history 10%
- familial ovarian syndrome
2) nulliparous
3) racial and social
Why screening for ovarian cancer is so
difficult?
• Anatomic location of the ovary, not easily
accesible
• Lack well defined precursor lesion and has
poorly defined natural history
• Low prevalence, need exquisite specificity to
avoid unnecessary intervention
• Lack of a good method
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Serum CA125
Transvaginal ultrasonogram
Multimodal
New method under investigation .
Serum CA125
• Elevated in 82% of ovarian cancer and <1% of
healthy women
• rising pattern over time preceded ovarian
cancer
• limitations: lack of sensitivity in Stage I disease,
poor specificity (elevated in benign and other
malignant conditions)
Ovarian Screening
• Not cost-effective
• May be considered in high risk population
• No place for population screening yet
Screening – US and CA 125
• “…there is no evidence available yet that the
current screening modalities of CA 125 and
ultrasonography can be effectively used for
widespread screening to reduce mortality
from ovarian cancer…”
• Only High risk population with BRCA1 or
BRCA2 Have annual or semiannual screening
with US & CA125.
Endometrial CA
Incidence : third commonest
malignant tumour of GT.
Age :
58
• High prevalence in the West, low (same as
ovarian ca)
• precursor lesion, atypical endometrial
hyperplasia
• accessibility of endometrium to sampling
• high cure rate for early disease
Cons: majority detected at early stage because
of abnormal bleeding esp PMB
Risk Factors
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DM, HT, obesity
nulliparity, anovulation, late menopause
exogenous estrogen
endogenous estrogen
smoking, white
familial history
PMB
1) carcinoma of endometrium
2) other gynecological malignancy
3) atrophic endometritis
4) endometrial hyperplasia
5) cervicitis/erosion
6) endometrial polyp
7) cervical polyp
14%
14%
20%
12%
8%
8%
• Tools explored
– pelvic ultrasound (>8mm endometrial thickness in
postmenopausal women) Karlsson 1995
– endometrial aspirate (inadequate sampling in
menopausal women)
End cancer Screening
• Not justified in population screening.
• End BX or Sono in;
• Obese-Estrogen exposure-Tamoxifen-Hx colon
& Endometrium Ca- is justified.
Conclusions
• Cervical cancer screening is the most
successful programme in gynaecological
cancers
• Ovarian cancer screening is not proven to be
cost-effective yet, may be considered in high
risk groups
• Endometrial cancer screening may be
considered in high risk groups