1. DR GEETANJALI S VERMA
CSI RAINY MULTISPECIALITY HOSPITAL

2. “For most of history, Anonymous was a
woman.”
Virginia Wool

3. HISTORY OF WOMEN’S DAY
• This was first celebrated on 19th March 1911
but is now celebrated every 8th March.
• Women join to celebrate the date that
represents equality, justice,peace and
development.
• International Women’s Day is rooted in the
struggle of women seeking to participate on
an equal footing with men.

4. Mary Wollstonecraft
• She was the first woman to
demand votes for women.
• 1792 her book entitled
Vindication of the Rights of
Women argued for equal
education, and for single
women to earn their own
living.
• She fought hard for women
even though she had much
personal unhappiness.
Unfortunately this led her to
being criticised and her ideas
dismissed by many, including
women.

5. Rich Victorian Women

6. • Although rich women had an easier life they had a common
denominator with poor women: they had no legal status. A
married woman’s earnings belonged to her husband. Her
property and goods all belonged to her husband.
• A woman could not vote.
• A woman could no go to university.
• She could not get a divorce on grounds of adultery (although
her husband could).
• It was almost impossible to get a divorce at all until 1857.
• The law said that children had one parent, a father. He
decided on their education and if a couple separated he could
refuse to let the mother even see them.

7. Caroline Norton
Caroline had a brutal husband who
accused her of adultery. She was
unable to defend herself in court as
she had no legal status. Her
husband took her children and also
all her earnings (she was a writer).
Caroline wrote on the Custody of
Infants and had some effect: 1839
the bill said children under seven
could stay with their mother if the
courts agreed she had a good
character. Caroline also wrote on
making divorce laws fairer.
Therefore she helped legal equality
for women.

8. Barbara Bodichon
Barbara supported the
Married Women’s Property
Bill in 1856. This resulted in
an Acts of Parliament
allowing women living with
husbands or those separated
to keep their own earnings
By 1882 women could own
their own property and give
it to whoever she wished.

9. Voting: arguments used against women
• Women are incapable of rational thought.
• Women are physically too frail and weak to
take on the burden of decision.
• Women are incapacitated by frequent
childbearing to bother to vote.
• Men will make the right decisions for them.
• If women have the vote they will upset the
current order and cause unpleasant
changes.

10. “In politics, If you want anything said, ask a
man. If you want anything done, ask a
woman.”
Margaret Thatcher

11. FROM NO VOTING RIGHTS TO RULING

12. “You educate a man; you educate a man. You
educate a woman; you educate a
generation.”
Brigham Young

13. Florence Nightingale
• Worked as a nurse in the
Crimean and drastically
reduced the death rate.
• Introduced nursing as a
profession and started a
nursing school.
• Involved in improving military
hospitals
• Used health statistics
effectively
• Hospital planning
• Community nursing.

14. Mary Seacole
• A nurse who used herbs
and natural remedies.
• Self funded to go to the
Crimean and nurse
soldiers on the battlefield
- a true ‘field’ nurse
attending the wounded
on the front line
• Sometimes called the
‘forgotten Nightingale’.

15. Women in WWI and WWII
Munitions factory

16. Mother Theresa
A Catholic nun who
devoted her life to
caring for the poor
and sick in Calcutta,
India. She was revered
as a living saint for her
work and won the
Nobel Peace Prize.

17. Marie Curie
• She won two Nobel prizes for
her work in science.
• Discovered radium with her
husband Pierre
• In WWI she equipped
ambulances with mobile X ray
units and drove them to the
front lines
• Her work helped X rays in
surgery
• Her research led to treatment
of cancer by radiation.

18. CANCERS IN WOMEN

21. BREAST CANCER

22. EPIDEMIOLOGY
Incidence:
• Breast cancer is the most common lethal
neoplasm in women.
• The incidence varies among different
populations
– 1 out of 8 women will have BC in her life--time.
– ~ 25 percent of women with cancer have BC.
• The incidence of male breast canceris about
1% of all breast cancer cases occur in men.

23. US incidence
– Affects 1 in 8 women living to 85yrs age
– Total cases 2008 : 211,000
– Total deaths : 40,500 (1/6th of female deaths)
 Ethnic incidence
Causacians – hispanic - asians – african american
 Stage at presentation
localised 58% (node -)
Regional 32% (node + / stage 3)

24. Age Incidence
by age 30 1 in 2,525
by age 40 1 in 217
by age 50 1 in 50
by age 60 1 in 24
by age 70 1 in 14
by age 80 1 in 10

25. RISK FACTORS
• Highly elevated RF (relative at 4 times risk)
– Female
– Age>50yrs
– Personal history of prior breast cancer
– Family history
– Atypical proliferative benign breast disease esp with family history
• Moderately elevated RF (relative at 2 - 4 times risk)
– Any 1st degree relative with breast cancer
– Upper SES
– Prolonged interrupted menses
– Post menopausal obesity
– h/o cancer ovary or endometrium
– proliferative benign breast with no atypia
• Slightly elevated RF (relative at 1-2 times risk)
– Moderate alcohol intake
– Menarche <12yrs old
– HRT/ OCP/ Diet

26. PATHOLOGY
Non – Invasive
Lobular (LCIS) Ductal (DCIS)
Invasive
Low Risk* Standard (high) Risk
Pure Tubular Ductal
Pure Mucinous/Colloid Lobular
Pure Papillary Medullary **
Pure Medullary ? Mixed
Squamous
* Requires careful pathology review
** atypical and mixed

27. CLINICAL PRESENTATION
The majority of carcinoma in situ, T1, or T2:
• Painless or slightly tender breast mass or have an
abnormal screening mammogram.
• Patients with more advanced tumors:
breast tenderness, skin changes, bloody nipple
discharge, or occasionally change in the shape
and size of the breast.
• Rarely patients may present with axillary
lymphadenopathy (which occasionally may be
painful) or distant metastasis.

29. SCREENING
MAMMOGRAPHY
Established Guidelines
Annual 2 view study in women 50 years of age
and older
• Meta - analysis
– 13 randomized trials
– 26% reduction in breast cancer

30. • Screening
– Patient without physical finding or symptoms
• MLO - mediolateral oblique (side)
• CC - craniocaudal (above)
• Diagnostic
– new symptoms - lump, thickening, skin change
– additional imaging including magnification
– additional evaluation including US

31. • INTERPRETATION
BIRADS - Breast Imaging Reporting and Data
System
Category Assessment Recommendations
0 Incomplete Additional views
1 Negative Routine - 12 months
2 Benign Routine - 12 months
3 Probable Benign F/U short term -6mos.
4 Suspicious Biopsy considered
5 Cancer suggestedAppropriate action

32. DIAGNOSIS
• Fine Needle Aspiration
• Ultrasound Guided Core Biopsy
• Excisional or Incisional Biopsy

33. TREATMENT
• NON INVASIVE DUCTAL
1) Complete Excision Alone Possible for low risk lesion, but
“low risk” difficult to define
2) Complete Excision + RT
Relative Contraindications
1 – in 2 or more
Margins need to be quadrants
negative, 2 – diffuse or malignant
>1mm, less than 10 appearing Ca++
mm. 2-3 mm usually Post excision Imaging 3 – persistent + margins
recommended - specimen mammogram 4 – not RT candidates
3) Mastectomy and/or prior RT
- post lump mammogram pregnancy
CTD –
lupus/scleroderma

34. Management Options – Radiation Therapy
• Excision Alone – recommended
• Post Mastectomy – unnecessary
• No effect on mortality
• Decreases Breast Recurrence Risk by 50% (1%
½%/yr)
Treatment is to Breast Only
Contraindications: Relative Contraindications
1 – in 2 or more quadrants
Omitted in low risk? 2 – diffuse or malignant appearing Ca++
controversial 3 – persistent + margins
4 – not RT candidates
< 5mm, low grade, unicentric prior RTpregnancy
CTD – lupus/scleroderma

35. NON INVASIVE LOBULAR
Features
Increased risk of subsequent invasive cancer (~ 1%/yr)
Likely to be bilateral
Management Options
Observation ( negative surgical margins NOT required)
No SLNBx or ALND is necessary
Bilateral mastectomies can be considered
Potential candidates for Tamoxifen or chemoprevention trials
Work-Up/Follow-Up
Bilateral mammogram, then yearly
Exam every 6-12 months

36. INVASIVE
Stages I – IIB + IIIA (T3 > 5 cm, N1 only)
Management Priorities
Surgery
Adjuvant Chemotherapy
Hormonal Rx* Radiation Rx*

37. CERVICAL CANCER

38. Where is the cervix?

39. Introduction
• Cervical cancer is the second most common cancer
among women and is the primary cause of cancer-
related deaths in developing countries
•
Cervical cancer, in women, is the second most common
cancer worldwide, next only to breast cancer. In India,
cervical cancer is the most common woman-related
cancer, followed by breast cancer

40. • Cancer of the cervix is the most common
female genital cancer in developing countries.
Every year about 500,000 women , acquire the
disease and 75% are from developing
countries.
• The cervical cancer burden in India alone is
estimated to be 100,000 .

41. •The number of deaths due to cervical cancer is
estimated to rise to 79,000 by the year 2010.
•The cancer mostly affects middle- aged women
(between 40 and 55 years), especially those from the
lower economic status who fail to carry out regular
health check-ups due to financial inadequacy.
In urban areas, cancer of the cervix account for over
40% of cancers while in rural areas it accounts for
65% of cancers as per the information from the
cancer registry

42. INCIDENCE

45. Risk factors and aetiology
 HPV (Human papilloma virus ) infection
mainly 16,18
the main aetiological is infection with
subtypes of HPV (16,18)
 Coitus at young age: <16 years old increased
risk by 50%
 Number of sexual partners: 6 sexual partners
or more increase risk by 14.2 folds.
 Smoking
Smoking for> 12 years increase the risk by
12.7 folds

46.  Long term use of the contraceptive pill
increase the risk due to increasing exposure
to seminal fluids.
 Barrier method decrease the risk
 Immuno suppresive pt
 Low socioecomic class

47. Type of patient:
• Multiparous.
• Low socioeconomic class.
• Poor hygiene.
• Prostitute.

48. Predisposing factors:
• Cervical dysplasia.
• Cervical intraepithelial neoplasia
• CIN III / CARCINOMA IN SITU
• THE LESION PROCEEDS THE INVASION BY 10-
12 YEARS The cervical cancer burden in

52. Symptoms:
Early symptoms Late symptoms
- None. - Pain, leg oedema.
- Thin, watery, blood tinged - Urinary and rectal
vaginal discharge frequently symptoms
goes unrecognized by the dysuria
patient. haematuria
- Abnormal vaginal bleeding rectal bleeding
Intermenstrual constipation
Postcoital haemorrhoids
Perimenopausal - Uraemia
Postmenopausal
- Blood stained foul vaginal
discharge.

53. Pathology type
• Squamous cell carcinoma- 90%.
• Adenocarcinoma- 10%.

54. What do you know about cervical
cancer screening?

55. What is a Pap test?
• Can find abnormal changes on the
cervix.
• Treating early changes can prevent
cancer of the cervix.

57. Pap test…

58. Cervical cancer prevention
• Pap smears performed once per year until
age 30
• >30 yrs - once every 3 yrs if pap and HPV
negative
• 75% reduction in cervical cancer in
countries with adequate screening

59. STAGES OF CANCER CERVIX
• Once cancer cervix is found (diagnosed), more
tests will be done to find out if the cancer cells
have spread to other parts of the body. This
testing is called staging.
• TO PLAN TREATMENT, A DOCTOR NEEDS TO
KNOW THE STAGE OF THE DISEASE.

65. TREATMENT
• Surgical.
• Radiotherapy.
• Radiotherapy & Surgery.
• Radiotherapy and Chemotherapy followed by
Surgery.
• Palliative treatment.

66. Surgical procedure
• The classic surgical procedure is the
wertheim’s hystrectomy for stage Ib,IIa, and
some cases of IIb in young and fat patient

68. PROGNOSIS
Depends on:
• Age of the patient.
• Fitness of the patient.
• Stage of the disease.
• Type of the tumour.
• Adequacy of treatment.

69. THE OVERALL 5 YEARS SURVIVAL FOLLOWING
THERAPY:
• Stage I -------80%
• Stage II-------50-60%
• Stage III-------30-40%
• Stage IV-------4%

70. HPV-associated Conditions
HPV 16, 18 Estimated %
Cervical cancer 70%
High/low grade cervical
abnormalities 30%-50%
Anal, Vulvar, Vaginal, Penile
Head and neck cancers
HPV 6, 11 10%
Low grade cervical
abnormalities
Genital warts
10%
RRP
90%
90%

71. Human Papillomavirus Vaccines
• HPV4 (Gardasil)
– contains types 16 and 18 (high risk) and types 6
and 11 (low risk)
• HPV2 (Cervarix)
– contains types 16 and 18 (high risk)
• Both vaccines are supplied as a liquid in a
single dose vial or syringe
• Neither vaccine contains an antibiotic or a
preservative

72. Human Papillomavirus Vaccines
• HPV4 vaccine is approved for
– females 9 through 26 years of age for the
prevention of cervical cancers, precancers and
genital warts
– males 9 through 26 years of age for the prevention
of genital warts
• HPV2 vaccine is approved for
– females 10 through 25 years of age for the
prevention of cervical cancers and precancers
– not approved for males or for the prevention of
genital warts

73. HPV Vaccine Schedule and Intervals
• HPV4- 0, 2, 6 months
• HPV2- 0, 1, 6 months
• ACIP recommends- 0, 1 to 2, 6 months
• ACIP has not defined a maximum interval
between HPV vaccine doses
• If the interval between doses is longer than
recommended continue the series where it
was interrupted

74. Conclusions
• Cervical cancer affects women in our
community
• Cervical cancer is a serious disease
– Risks just from preventing cancer
– 30% mortality from cervical cancer
– Long term effects after treatment for cervical
cancer
• Cervical cancer is preventable
– Regular pap smears
– HPV vaccination