Screening for
CANCERS
Dr. Shobha dhananjaya
Professor in OBG
JJMMC, DVG

Definition:
• ‘Screening’ means looking for early signs
of a particular disease in healthy people
who do not have any symptoms.
• Screening cannot prevent cancer, it can
only find it as early as possible and help in
early radical cures.

• Breast cancer
• Cervical cancer
• Endometrial (uterine)
cancer
• Ovarian cancer

Overview of
Breast Cancer

Breast Cancer Facts
 2nd leading cause of death
 2nd most common cancer
 Incidence increases with age
 All women are at risk

Types of Breast Cancer
Ductal Carcinoma
common
Lobular Carcinoma
rare

What causes Breast cancer
• 90% of breast cancers are due to genetic
abnormalities- aging process and the “wear and
tear” of life.
• 5-10% of cancers are due to an abnormality
inherited from your mother or father.

Risk Factors for Breast Cancer
Gender: female (1% males)
Race: more common in whites
Age: increases as a woman gets older.
Relative : (mother or sister)
Menstrual history :early onset,
late menopause
Childbirth: first child After the age of 35
or having no children at all
Pregnancy and breastfeeding are protective against breast cancer

Risk Factors for Breast Cancer
Obesity
Diet: Fat
Alcohol
Lack of Physical Activity ; Stress
Radiation Exposure
History of cancer: breast, uterus, cervix, ovary
Hormones: estrogens in Hormone replacement
therapy & Birth control pills
> 70% have no risk factors

Symptoms of Breast Cancer
Early breast cancer may not have symptoms.

Diagnosis of Breast Cancer

Prevention
Breast Cancer Risk Factors
thatcan be controlled
All
women are
at risk
Obesity Exercise
Breastfeeding Alcohol
Hormone
Replacement
Therapy
Not having
children

Screening For Breast Cancer
A GoodBreast Health Plan
• Self Awareness- Monthly Self
Exams
• Clinical Breast Examination
• Mammograms

Screening
Average-size lump found by woman
practicing occasional breast self-exam
(BSE)
Average-size lump found by woman
practicing regular breast self-exam
(BSE)
Average-size lump found by first
mammogram
Average-size lump found by getting regular
mammograms
r
i
z

Breast Self Examination (BSE)
• Opportunity for woman to
become familiar with her
breasts
• Monthly exam of the
breasts and underarm
area
• May discover any
changes early
• Begin at age 20,
continue monthly

When to do BSE
• Menstruating women- 5 to 7
days after the beginning of
their period
• Menopausal women -
same date each month
• Pregnant women –
same date each month
• Takes about 10 minutes
• Perform BSE at least
once a month
• Examine all breast tissue

Why don’t more women practice BSE
• Fear
• Embarrassment
• Youth
• Lack of knowledge
• Too busy, forgetfulness

Clinical Breast Examination
• Performed by doctor or
trained nurse practitioner
• Annually for women over
40yrs
• At least every 3 years for
women between 20 and
40 yrs
• More frequent
examination for high risk
patients

Mammography
 X-ray of the breast
save lives in patients
50-70%
 Normal
mammogram does
not rule out
possibility of
cancer completely

Women
(asymptomatic) 40
years of age and
more should have a
MAMMOGRAM
every year.

Treatment for Breast Cancer
• Surgery
• Radiation Therapy
• Chemotherapy
• Hormonal Therapy

Breast Reconstruction
Post surgical Expanders and Implant

Tissue and Implants
Combined

Prognosis after Breast Cancer
5-Year
Survival (%)
10-Year Survival
(%)
Stage 0 95 90
Stage I 85 70
Stage II 70 50
Stage III 55 30
Stage IV 5 2

Myths•Touching the breasts too often will lead to cancer
•Talking about cancer causes cancer
•Using illegal drugs causes cancer
•Herbs cure breast cancer
•A bruise on the breast will lead to breast cancer.
•If an incision is made during breast cancer
surgery the cancer will spread.
•Getting too many mammograms leads to
breast cancer.
•A breast cancer diagnosis is an automatic death
sentence.

Facts• Breast cancer commonly affects older
women
• If you have a risk factor for breast
cancer, you're likely to get the disease
• Mammograms are only used to
evaluate
breast lumps.
• Breast cancer is preventable

• Cervical cancer is the most
common cancer in women in
developing countries.
• Lowermost portion of the uterus
(neck of the womb)

• Biopsy — Removal of a small sample of
tissue for examination under a
microscope; used for the diagnosis and
treatment of cervical cancer and
precancerous conditions.
• Carcinoma in situ — Cancer that is
confined to the cells in which it originated
and has not spread to other tissues.

CERVICAL CANCER:
• Cervical cancer is a malignant
tumour arising from the cells of
the neck of the womb which is the
lower part of the female
reproductive organ.

Human papillomavirus( 90%) –STI
Multiple sexual partners
Sexual relation before the age of 18

• Smoking
• Weakened immune system
• Several pregnancies
• Giving birth at a very young age
• Long-term use of the contraceptive
pill

• Post coital bleeding
• White discharge
• Pelvic pain
• Cachexia

PAP test

• HPV DNA test
• HPV DNA test involves
collecting cells from the cervix for
lab testing.

• CT (computerized tomography)
scan
• MRI (magnetic resonance imaging
scan)
• Pelvic ultrasound

• Chemotherapy
Chemotherapy is the use of
chemicals (medication) to destroy
cancer cells. Cytotoxic medication
prevents cancer cells from dividing
and growing

• Radiotherapy
Radiotherapy works by damaging the
DNA inside the tumor cells,

–Laser surgery - a narrow beam of
intense light destroys cancerous
and precancerous cells.
–LEEP (loop electrosurgical excision
procedure) - a wire loop which has
an electric current cuts through
tissue removing cells from the
mouth of the cervix.

– Flavonoids are chemical compounds
in fruits and vegetables that are
thought to be a leading source
protection against cancer. The
flavonoid-rich foods are Apples, Black
beans, Broccoli, Brussels sprouts,
Cabbage, Garlic, Onions, Soy,
Spinach.

– Folate (a water-soluble B vitamin) reduce
the risk of cervical cancer in people with
HPV. Foods rich in folate include breads,
Lentils, Orange juice and Strawberries .
– Carotenoids, a source of vitamin A, are
also helpful in preventing cervical cancer
risk. Foods such as carrots, sweet
potatoes and pumpkin are rich in vit. A.

HPV (human papilloma virus)
vaccine
• 3-doses ( 0-1-6 months )
• CERVIREX

–Safe sex
–Cervical screening
– avoid multiple sexual partners
–Delay first sexual intercourse
–avoid smoking

INTRODUCTION
Incidence of endometrial cancer is very low
in India.
Highest in Delhi – 4.3/ lac
Bangalore – 4.2/ lac
Mumbai – 2.8/ lac
(GLOBOCAN - 2008)

21-50 lb over wt.- 3 times
>50 lb over wt.- 10 times
Most common cause of
endogenous production of
estrogen (Williams gyne)
Coexisting medical condition /
sequele- HTN, DM & Gall
bladder disease increases risk
(Williams gyne)

obesity
Corpus
cancer
Corpus cancer syndrome

Risk also increases with :
> Duration of therapy
> Cumulative dose

Preventing factors
Oral contraceptive pills-
1 yr. of use confirms 30% reduced risk
Risk reduction is upto 10-20 yrs.
Progestin component has chemo protective role
Progesterone IUCDs confirms long term protection.
Earlier age of menopause

Screening tests
 Pap smear
 Progesterone challenge test
 TVS
 Endometrial biopsy
 VABRA or Pipelle

EARLY DIAGNOSIS & TREATMENT
If a lady comes with:
 Premenopausal AUB
 Post menopausal bleeding per vagina
25% of the endometrial cancer occurs premenopausally.
5% under the age of 40 yrs.
Early diagnosis & prompt treatment has high cure rate.

10% (HNPCC or predisposition for endometrial cancer
alone)
Autosomal dominant
What to do in these patients ???
There are 2 alternatives-
Annual pelvic examination, TVS & EB from the age of
30-35yrs.
OR
Prophylactic TAH & BSO after completion of child
bearing (Preferred Alternative)

Endometroid adenocarcinoma
• ~80% of endometroid
carcinoma
• Composed of glands that
resemble normal endometrial
gland
• D/d- Atypical hyperplasia-
Differentiated by presence of
invasion.

Simultaneous tumors of
endometrium & ovary
Most frequent simultaneously occurring genital
malignancies
Incidence- 2-4%
Both are well differentiated
Prognosis -Excellent
Mostly postmenopausal
C/f : AUB (ovarian ca diagnosed incidentally)
29% of endometroid adeno ca. of ovary have
associated endometrial cancer.

Clinical features
Average age of presentation- 60 yrs.
Mostly 6th & 7th decades of life.
5% presents premenopausally (Novaks 15th ed.)
Presenting symptoms:
Vaginal bleeding
Vaginal discharge (may be purulent)
Pelvic discomfort/ pain (due to uterine enlargement
due to mass or hematometra or pyometra or
extrauterine d/s spread)
< 5% - Asymptomatic

Causes of post menopausal BPV ???
Post menopausal BPV
Genital
Uterine
Endo. Atrophy(60-80%)
Estrogen replacement (15-25%)
Endo. Hyperplasia (5-10%)
Endo. polyp (2-12%)
Endometrial Ca (10%)
Extra-uterine
Ca. cervix, vagina & vulva
Atrophic vaginitis
Traumatic bleeding
Non-genital
Urinary
Gastro intestinal
Hematological

History &Physical examination
History: Obesity, Diabetes, Hypertension, bladder & bowel
symptoms
Gen. Examination:
Weight
LN enlargement (Inguinal, abdominal)
Breast examination
P/A exam: +ve in advanced disease
Ascites
Hepatic or omental metastasis
Pelvic exam: Vaginal introitus, sub urethral area, vagina, cervix
P/V exam., P/R exam. (uterus, adenexa,
parametrium, cul-de-sac)

investigations
Routine investigations
Transvaginal sonography*
Office based endometrial biopsy (VABRA or Pipelle)*
Endocervical curettage (in suspected cervical
pathology)
Hysteroscopy
Dilatation & Curettage
Only used if there is:
Cervical stenosis
Recurrence of bleeding
after –ve OBEB
Inadequate sampling in
specimen

Pre treatment evaluation
Examination:
Routine investigations:
ECG
Chest X-ray
CA-125- ↑sed in advanced metastatic Ca.
USG & MRI- Degree of invasion
Cystoscopy, Colonoscopy, IVP, Barium enema- acc.
to symptoms

Surgical Staging
Hysterectomy
B/L Salpingo-oopherectomy
Biopsy of all metastatic deposits
Peritoneal fluid cytology
Cytology in clockwise fashion
Pelvic & Para-aortic LN dissection only in high
risk-
Tumor size >2cm.
Grade-III tumor
Non endometroid
tumor

treatment
Exploratory laparotomy
Biopsy of any suspicious lesion
TAH-BSO
Peritoneal cytology
Resect any enlarged LN
Selective Pelvic & Para-aortic
lymphadenopathy

Follow up History & Physical examination (Most effective method):
1st 2 yrs.- Every 3-4 mths
Then- Every 6 mths
 Chest X-Ray:
Every year
 CA-125: For patients :
Who have elevated CA-125 @ the time of diagnosis
Have extrauterine disease

Recurrent disease
~25% of the treated early endometrial cancer
recurs.
>50% recurs in 1st 2
years
~75% recurs in 1st 3
years

Points to remember
Recurrence is less when the surgery
+radiotherapy
Metastasis to.- Lung, Abdomen, Lymph nodes
(Aortic, Supraclavicular, Inguinal), Liver, Brain
& Bone

Clinical features

Ovarian
Cancer
91

Introduction.
 Cancer cell growth is different from normal cell growth.
1. Instead of dying, cancer cells continue to grow and form
new& abnormal cells.
2. Cancer cells can also invade (grow into) other tissues,
Why the Cells become cancerous ???
Due to damage in DNA.
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Anatomy and physiology
93
female organs (glands producing sex hormones
and the ova)
size: One ovary is long, 2 cm wide and 1 cm thick
Shape: almond shape.
Location: on each side of the uterus

Symptoms
Early symptoms of ovarian cancer:
•Pain in the pelvis
•Back pain
•Indigestion or heartburn
•More frequent and urgent urination
•Pain during sexual intercourse
As ovarian cancer progresses these symptoms are also
possible:
•Nausea, Weight loss, Breathlessness, Fatigue (tiredness)
•Loss of appetite

Causes
 Family history
 - Age
 - High number of total lifetime ovulations.
 - Early start of menstruation and Late start of
menopause .
 - Breast cancer.
- HRT (Hormone replacement therapy) .
- Obesity/overweight.
- Endometriosis.
- Inherited genetic syndromes.
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Stages
stage:1
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Stage:2
98

Stage: 3
99

Stage:4
100

Diagnosis of ovarian
cancer
The following tests are used to diagnose ovarian
cancer:
 Blood test
 Ultrasound
 Laparoscopy and possibly Endoscopy
 Abdominal fluid aspiration
 Chest X-ray
 CT (computerized tomography) scan
 MRI (magnetic resonance imaging) scan
 Positron emission tomography (PET scan)
 Biopsy 103

Treatment
Treatment for ovarian cancer consists
of
1.surgery
2.chemotherapy
3.combination of surgery with
chemotherapy
4.radiotherapy
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Side effects of
chemotherapy
 Diarrhoea.
 Hair loss.
 Loss of appetite.
 Mouth sores.
 Anaemia.
106

RADIOTHERAPY
Side effects -
•Bladder infections.
•Diarrhea, Constipation.
•Irritation, darkening of your skin
•Nausea, Frequent urination, Abdominal pain
PREVENTION:
Oral contraceptives
Gynaecologic surgery
•tubal ligation
•hysterectomy
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Conclusion
 ovarian cancer is less common and early diagnosis
may save lives.
 symptoms are similar to that of irritable bowel
syndrome, pre-menopause, endometriosis, gall bladder
disease
 It is the time to BREAK THE SILENCE….. educate
yourself and the women you love !!!
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Thank
you
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