Clinical Manifestation and Management of Cancer of the Cervix-Lesotho & Developing

countries

Sejojo Phaaroe,.M.T,;C.T(I.A.C); M.I.B.M.S;

A Clinical Cytologist

CACX IS A HEALTH PROBLEM

PHILOSOPY• IF WE DON’T LEARN WE WILL SHRINK

AND DIE• IF WE DON’T SHARE WE WILL FORGET

THE LESSONS• IF WE FORGET, WE WILL CONTINUE TO

REPEAT THE MISTAKES• IF WE LEARN AND SHARE WE WILL

GROW AS A TEAM• THE KEY BENEFICIARIES OF THIS

FORUM ARE ALL CARE GIVERS AND AFFECTED PEOPLE IN THIS COUNTRY

C SA N IT B EOLVEDCSA N IT B EOLVEDBy Cytologists by MEDICAL TEAM ? By us all in here ? – yes!

EducationFinished

H igh School

PsychologicalCounseling

ConflictResolution

SocialStrengthen-

Fam ilyCom m unity

EconomicNew JobsLegislative (law)

Outlaw F irearm sM ore Prisons/

Longer Sentences

W KS ?

H A T IN DO F O L U T IO N

Biological/Medical

Pharm aco-Therapy

ESTABLISHMENT OF CERVICAL CANCER SCREENING POLICY IS THE

ONLY RESOLUTION TO THE PROBLEM IN LESOTHO

• By S. Phaaroe - July2004 Seboping Radio Les• S. Phaaroe LMA Journal April 2005• Dr Cronje – Sebeta Memorial Lecture- LMA

AGM 2006- ( The financial Muscle I contacted which was willing to give financing into the problem of Cervical cancer in Lesotho said the was no infrastructure for the implementation of the intervention programme”

• Dissemination of study of incidence of CACX Lesotho-–S.Phaaroe.LAF- SAHCS-LMA forum- 30/09/2006

FACT FACTORY

BOYS LBCN OFFICIAL LAUNCHING

BREAKING THE SILENCE PINK ALL OVER

National stake holders Education/Information-Magnitude of cancer cx

Gyaenacology, Oncology, Radiology, Pharmacy etc

FAMILY H, ED, PLANNING & Men’s clinics, private clinics linkage with NGO’S in a health system

Education , Academic centers of excellence & other Research institutions

Chiefs, local government, village councils, NETWORKS

LEGAL SYSTEMS, Policy makers, International conventions, Regional strategies

EMPLOYMENT FORCE/ Government Institutions Insurance Levy, & Industry

Technology INCUBATION CENTRES, SMME’s , Joined Bilateral commissions/ agreements

CYTOPATHOLOGY BIOMEDICAL SCIENCE RESEARCH LAB is the central organ

Well women groups/ church/ women in Law, every body, Support groups/ men leagues

S. Phaaroee M.T C.T(IAC), AIBMS

PSBH- REPORT Boston University 2005

Etiological factors behind cancer of the Cervix

• women -Early coitus• Multiparious women• Multisexual partners• It varies with race [genetic

susceptibility ,etc]• High in low socio-economic

stata [malnutrition,poor health facilities]

• Poor hygiene[smegma factor]• Sperm factor[acridine histones]• Women with boyfriends with

CA. penis

.Hormonal contraceptives /preparations like depo [Stern et al 1977]

• STI’s- infection, etc.• Viral HIV,• Viral HPV, • Viral H Herpes • Smoking [TARR/hetero]• Alcohol drinking• Drugs (Diethylstilbestrol-

DES),cyclophosphamide • Pelvic irradiation.• History of cancer from other sites

e.g uterus, colon.

Popelo/

Molomo-oa popelo

/ Mahe

molomo oa popelo bophelong ba ‘M’e

Bonyaneng- Youth

Boroetsaneng- Purberty

Bo ‘M’eng- Adult hood

BoQhekung – Post Menopause

Situation in Lesotho• Lesotho & other developing countries have been unsuccessful in

implementing C.C.S.P• Barriers : Insufficient Infrastructures• Inadequate RX for precancerous & cancerous cases• Cost effective approach was to target high peak age of cacx cases ten

yrs before invasive CACX• Problem observed was that in Tygerberg the peak up incidence is at

25 yrs for CIN 3• Also supported by Learmonth et.al SAMJ Vol 85 pg 52 Jan 1995.

And Lesotho is no different• The possible shift is as a result of incidence of HIV• Screening of all at risk women in the population is targeted• Perform Treatment of only severe Dysplasia

GARDASIL® (Quadrivalent Human Papillomavirus [HPV Types 6, 11, 16, 18] Recombinant Vaccine)

Classification of Histological FindingsCINCIN11 NormalNormal

CIN 1/LSIL CIN 1/LSIL +HPV+HPV

(condyloma)(condyloma)

CIN 1/LSILCIN 1/LSIL(mild (mild

dysplasia)dysplasia)

CIN 2 /HSILCIN 2 /HSIL(moderate (moderate dysplasia)dysplasia)

CIN 3 /HSILCIN 3 /HSIL(severe dysplasia/CIS)(severe dysplasia/CIS)

Invasive Invasive CancerCancer

Histology of Histology of squamous squamous cervical cervical epitheliumepithelium11

Basal cell

Basal membrane

CIN caused by HPV can clear without treatment; however, rates of CIN caused by HPV can clear without treatment; however, rates of regression are dependent on grade of CIN.- With HIV infection the regression are dependent on grade of CIN.- With HIV infection the rate can not be predictedrate can not be predicted

Confirmation method

LSIL HSIL HSILHIV has caused a shift in regression

N LSIL HSIL HSIL

Clinical Staging of CACX• Precancer: Dysplasia- a degree of epithelial abnormality occurs

when normal cells undergo bad changes but too early to be called malignant, however if the condition is left untreated will progress to cancer. CIN 1, 2, and CIN3

• There is no agreement over the progression rate• Stage CA CX 1.O = CAO= CIN3/CAO= confined to surface

epithelium• CACX stage 1.A= Less or equal < 5mm invasive beyond

stroma= micro-invasive CACX• CACX stage 1.B= > 5mm invasive beyond stroma• Stage CACX 2. A = Spread beyond CX• CACX 2.B =Early para-metrium invasion

Stage CACX 3• More Extensive spread• CACX 3.A = Involves lower third of vagina• CACX 3.B= Parametrium and pelvic side wall

metastasis

• STAGE CACX 4• Extension to bladder• Rectum• True pelvis• Distant organs

Classification of Cancer of the cervix

• 90% squamous of the cervix• A) keratinizing squamous carcinoma[good]• B)non keratinizing[poorly differeniated sqcacx[p]• C)small cell squamous carcinoma [WORSE] • 3%Adenocarcinoma of cervix• 2% Adeno-squamous of cervix• 2% Adenoacanthoma of cervix• 3% Clear cell carcinoma of cervix• The cancers respond differently to treatment so

prognoses, and type of treatment varies

Signs and symptoms/ clinical presentation• Early signs:• Abnormal vaginal bleeding which could be • Intermenstrual• Post coital bleeding• Post menopausal bleeding• Watery offensive vaginal discharge• The cervix is friable , hard with contact bleeding on examination( the

dysplastic cells have poor cohesiveness, so the underlining vascular system in the lamina propriae become exposed.)

• The Cytologist should expect micro-biopsies or an inadequate smear scraping because of blood

• The Clinician should blot the blood with 5%CH3COOH

Late signs

• Pain• Dyspareuria(pain during intercourse)• Urinary symptoms: frequency in urination• Dysurea• Hematuria• Vesico-vaginal and or recto-vaginal fistula• Anaemia, Cachexia• Bone pain, due to metastases

Investigations and Laboratory Diagnoses of advanced cancer

• General physical examination by Nurses/Doctors• Pap smear –CYTOLOGY • PCR-for HPV [DNA/RNA]• Biospy for Histology- Cone • Colposcopy• FNAB –cytology of pelvic masses or suspicious Lymph nodes• Molecular biology & Cell markers e.g CEA,EMA• Radiological studies: - Chest X-ray for any Lung Metastases,bone etc• Excretory Urogram- to determine urinary function• Cytoscopy- to exclude bladder involment• Blood Tests: FBC, -

Treatment of Advanced Cancer of The Cervix• Types of Treatments available• Cone biopsy-Lesotho• Surgery(TAH.B.S.O)--Lesotho • Laser Beam Therapy• Radiotherapy• Rarely Chemotherapy• The choice of RX depends on the size of the tumor, patient’s age and

general health fitness• Treatment varies on oncology center to center• Stage 1.0: uterine function is conserved, CONE BIOPSY, or Laser

therapy is used• Hysterectomy, only conservation of ovaries in patients under 40 yrs( as

ovarian hormones are still of value

TREATMENT OF STAGES 1-4• CACX 1A: Hysterectomy only• 3 radium insertions are done if the patient is still fit for surgery• CACX 1.B: Radium and lymphadenectomy• CACX 2..A: as for 1.B but external beam therapy if the tumor is very

large( to shrink the tumor)• CACX 2.B: 1º rx Radiotherapy to reduce tumor bulk –external and

internal radiation,and this is followed by Radical hysterectomy in selected patients

• CACX 3. As for stage 2.B• CACX 4: a) rx is of PALLIATIVE(symtopms which occur)• b) Urinary diversion or colostomy where indicated is done to obviate or

because of fistula

The “Total” Pain Concept

Spiritual

Emotional

Financial

Physical

•Guilt•Why me?•Life closure issues

•From disease•From treatment

•Direct costs•Indirect costs

•Loss of function

•Coping abilities

PAIN

Chemotherapy• It is not effective and popular• Various trials are being carried out at Groote schuur• Drugs commonly used are• Cyclophosphamide• Cisplatiunum• Adriamycin• Melphalan• Special drug monitoring facilities need to be inplace to be able to

administer these drugs• Cyclophosphamide is also known to be carcinogenic to the Kindeys

& Bladder• It is also a drug of choice for HPV infections

Surgery

• General Nursing care is important • Pre & post operative care and counseling • Specific colostomy • Urostomy care are highly needed to effect

better results

Radiation therapy[internal radium]• Preparation of the Patient :• Patient is Admitted 12-24 hrs prior to insertion• During this time , a full medical and nursing history will be taken

and routine investigations include• Full blood count, temperature, pulse, respiration & blood

pressure, urinalyses, chest X-RAY• Consent has been given by the patient• The Oncology nurse should also take time to explain the

procedure and its implications to the patient as well as answering any questions the patient may wish to ask

• Special sensitivity is needed when dealing with premenopausal patient, as hysterectomy will render them unable to bear children

Radiation therapy Cont----• It is not obvious that treatment by irradiation will produce sterility.

This needs explanation to both husband and wife and may increase anxiety already present as a result of a diagnoses

• The patient will need to know why visits from the nursing staff and relatives must be restricted so that she does not feel isolated or deserted & this must be repeated many times

• The evening prior to insertion the patient should have a thorough shave and the bowels opened by means of of suppositories or an enema

• Night sedation will usually be given to ensure adequate rest, and the patient is maintained nil per month from the night before the procedure

• Premedication is given before the patient leaves to Theatre.

Insertion of applicatiors. Available information is there on

request- From Sejojo Phaaroe mainly for

oncology nurses Surgical oncologists

, Radiologists gyaenacologists

andCytologists

Use of Inexpensive treatment• Out patient treatment techniques such as Cyotherapy can

provide 80-90% cure of CIN3 without sophisticated use of Colposcopy

• Rx of only severe dysplasia will increase overall cost effectiveness

• Lazar beam therapy• Cone Biopsies also give a treatment and diagnostic pathway• This stress the need for High population screening• Screening for HPV, and HIV to identify women at high risk

for developing Cancer of the CX• PAP test is the only cost effective screen for HPV

Spread of cancer of the Disease• Like a CRAB, the lesions tends to spread in all directions• Into the vagina by direct extension• Upwards into the body of the uterus –direct • Laterally into the parametrium, i.e. connective tissue surrounding

the uterus• Into adjacent organs i.e., bladder & rectum• Via the Lymphatic to regional lymph nodes• Via Pelvic veins to Liver, Lungs, and bones• Haematogeneous dissemination• Expect to find the CERCIX cancer cells every where• This express the need for establishment & advancement of systemic FNAB

cytology services

Recommendation from Sejojo and co-worker’s Lesotho documents

• Education of Policy makers about the problem of CACX and importance of PAP TEST screening

• Ed. On modalities of follow up and treatment• Establish how feasible, public health oriented approaches to prevent/reduction

of incidence & mortality CQI TEAM• Efforts should focus on Research into the extend of the problem and

establishment of pilot projects to test the feasibility of CACX screening and treatment in a given setting(Pap test,HPV serotypes in Lesotho,Vaccine development)

• Establish limited screening programmes that target High risk women for frequent screening [Discuss infrequent

• Establishment of limited treatment programmes that target high risk women for frequent screening[Discuss infrequent

• Establishment of a National Cancer Policy and Registry- A Bill and an Cervical cancer screening ACT 2008 eg.

Notifications and Information flow about cancer –

Improvement of efficacy and accuracy of Cytology services

• Establish & improve Country training programmes for Clinical Cytologists to required International status

• Establish & improve Country training programmes for Oncology nurses and clinicians

• Initiate improved Histological diagnoses of all suspected lesions before, by strengthening Lab capacity, independence from diagnostic lab and budgets

• Authorities & Decision makers commitments