Obgyn Week 4b

Cervical Dz, Gynecologic Cancers

Cancer

• Most common cancers in U.S. women

By occurrence By mortality

Breast Lung

Lung Breast

Colorectal Colorectal

Endometrial Ovarian

Non-Hodgkin lymphoma

Pancreatic

Cancer

• Most common cancers in U.S. men

By occurrence By mortality

Prostate Lung

Lung Prostate

Colorectal Colorectal

Bladder Pancreatic

Melanoma Leukemia

Cancer

• General Cancer terms:– Stage: determined by clinician; is the

degree of invasion of the tumor; usually on a scale of 1-4

– TNM staging where n=nodes, m=mets– Grade: determined by pathologist; is the

degree of resemblance of the tumor to its surrounding tissue• The higher the grade the less differentiated

Cancer

• More general cancer terms:– Carcinoma: tumor derived from epithelial

cells– Sarcoma: derived from connective tissue– Adeno-: prefix to denote glandular

involvement– Lymphoma: derived from hematopoietic

cells (blood cancer)

Cancer• TCM description of process

(from Dr. Fritz)– Deficiency state (improper diet/lifestyle/emotion)– External pathogen invasion creates disharmony– Blood stastis/phlegm accumulation --> tumor

formation– Perpetuation of internal cold-heat cycle– Body unable to disperse, tumor grows

PAP

• Part of the yearly well-woman exam

• PAP smear (named after Dr. Papanicolau)

• Is a screening tool only

• Looks for abnormalities in cervical cells

• Is susceptible to false + and false - results– False negative rate about 5-20%– False positive due to Trichomonas or HSV

infections or if history of chemotherapy

PAP• Screening guidelines:

– Beginning at age 18 or upon sexual activity– ACOG (American College of Gynecology)

recommends annual screening indefinitely– American Cancer Society recommends

screening at least every 3 years (if no abnormal results); more frequent if patient is at increased risk

– Both recommend pelvic exam annually for all women over 40 years old

PAP

Cervical Dysplasia

• Precursor to cervical cancer

• Aka Cervical intraepithelial neoplasia

• Dysplasia = abnormal tissue development; refers to pre-cancerous changes in cervical cells

*Cervical cancer of squamous cells is a preventable disease

Cervical Dysplasia

• Risk factors:– Early age 1st intercourse; 2x risk if age 14 or 15– More than 3 sexual partners– Giving birth before age 22– Cigarette smoking (2x risk)– Low socioeconomic status– OCP use esp. if for 5-10 years (barrier methods

protective)– Alterations in immune status (HIV, Lupus)– Current or past chlamydia infection– Vitamin A, C, and folate deficiency

Cervical Dysplasia

• Pathology:– Cervix covered with mucus membrane– During adolescence, columnar epithelium

changes to squamous epithelium– Squamo-columnar junction is most

susceptible to dysplastic changes– Junction surrounds cervical os; recedes

into os around menopause

Cervical Dysplasia

Cervical Dysplasia

• Mild dysplasia: basal layer thickens to about the bottom 1/3rd of membrane

• Moderate: basal cells thicken to middle 3rd

• Severe: basal cells thicken to more than 2/3rd of membrane

• Carcinoma in situ: basal cells through entire thickness of membrane

Cervical Dysplasia

Cervical Dysplasia

Cervical Dysplasia

• Classification systems (PAP smear)– Bethesda Classification:

• Low-grade SIL squamous intraepithelial lesion– Evidence of HPV– Mild dysplasia

• High-grade SIL squamous intrapeithelial lesion– Moderate to severe dysplasia– Carcinoma in-situ

Cervical Dysplasia

• Traditional Classification– CIN I: mild dysplasia– CIN II: moderate dysplasia– CIN III: severe dysplasia– Normal– Metaplasia– Inflammation– Atypia - cells are not dysplastic but not ideal - show

evidence of repair (from infection, inflammation, etc)

ASCUS: atypical squamous cells of undetermined significance

AGCUS: atypical glandular cells of undetermined significance

Cervical Dysplasia

• Etiology– HPV: Human Papilloma virus

• Most evidence of causal relationship• Subtypes 16 and 18 most aggressive: 18

months until cancer development

– HSV II: Herpes simplex virus • Virus detected in cervical cancer tissue• Antibodies found in blood of women with

cervical dysplasia and cancer• No clear cause-effect determined (yet)

Cervical Dysplasia

• Approximately 70% women have HPV infection at some point in their lives

• Most infections and subsequent dysplasia regress on their own

• ~10% cervical cancer cases appear to rise in absence of detectable HPV DNA

Cervical Dysplasia• Evaluation:

– Colposcopy: magnification of cervical transformation zone (squamo-columnar junction)

– Biopsies of tissue w abnormal appearance– Large abnormal transformation zone correlates

with high-grade lesions– Small abnormal transformation zone correlates

with low-grade lesions– If entire transformation zone not visualized, need

LEEP or conization procedures to sample endocervical canal

Cervical Dysplasia• Various levels of dysplasia will have

different treatment plansLow-grade - often can recheck in 3-6 months

High-grade- colposcopy to determine extent• Cone biopsy if indicated• Re-PAP more frequently if indicated

Cervical Dysplasia• Conventional Management:

Cryotherapy: frozen carbon dioxide or nitrous oxide applied to abnormal tissue via a probe

– Purpose is to eradicate abnormal epithelium a few millimeters thick

– No anesthesia required– May result in cervical stenosis– Cure rate 91% CIN I-II; 78% CIN III– Follow up in 4 months to visualize tissueLaser therapy:– Vaporizes target tissue– Equipment more expensive and requires specialized

training

Cervical Dysplasia• Naturopathic Management

– Nutrition and supplementation• Focus on colorful veggies and fruits, cruciferous veggies• Folate 10 mg/day• Vitamin E 400-800 IU/day• Green tea capsules• DIM or I3C - both

– Vaginal suppositories• Vitamin A nightly for 6 nights• Green tea nightly for 6 nights• (alternate weeks for 4-12 weeks)• Escharotic treatments also available - weekly, in office

– Current research suggests cervical dysplasia may be evidence of FOLATE deficiency

Cervical Dysplasia

• HPV vaccine: Gardasil– Approved by FDA June 2006– Protects against 4 HPV strains (out of

possibly hundreds): HPV 6, 11, 16, 18– Vaccine studied for 4 years before release– Already on vaccine schedule for children– Marketed to girls as young as 11 years old– Research underway to study vaccine on boys

Cervical Dysplasia

• Reported Gardasil adverse effects:– Collapsing after vaccine– Dizzy spells– Fainting– Seizures– Death

• Vaccine recipients may still contract HPV and develop cervical dysplasia

• Lifestyle choices, screening, and prevention are key against cervical ca.

Cervical Cancer

• Third most common gynecologic malignancy

• Eighth most common malignancy in US women

• 4,600 deaths annually

• Mean age 50 but may occur as young as age 20

• HPV types 16, 18, 31, 33, 35, 39 increase risk

• Cancer occurs when cervical dysplasia or carcinoma in situ penetrates the basement membrane and invades surrounding tissue

Cervical Cancer

Cervical Cancer

• Most (80-85%) cervical cancer is squamous cell carcinoma

• The rest is mainly adenocarcinoma – No clear relationship to HPV etiology

• Rare: – sarcoma, small cell neuroendocrine tumors,

clear cell adenocarcinoma

Cervical Cancer

• Spread:– Via direct extension to surrounding tissues– Via lymph to pelvic and para-aortic lymph

nodes– Via lymph to extra-abdominal lymph nodes :

left scalene and left supraclavicular nodes – Via blood to distant tissues - possible but

rare in cervical cancer (Lung, liver, bone)

Cervical Cancer• Main symptoms:

– CIN: usually asymptomatic and discovered with PAP smear

– 50% women with cancer have never had a PAP or haven’t had one in over 10 years

– Early stage: irregular vaginal bleeding (postcoital, intermenstrual, menometrhorrhagia)

– Advanced: foul-smelling discharge, abnormal bleeding, pelvic pain

– Late-stage: obstructive uropathy, back pain, leg swelling

Cervical Cancer

Staging is most important determinant of prognosis

• Stage 0 - full-thickness involvement of the epithelium without invasion into the stroma (carcinoma in situ)

• Stage I - limited to the cervix• Stage II - invades beyond cervix• Stage III - extends to pelvic wall or lower third

of the vagina• Stage IV - metastasis

Cervical Cancer

Cervical Cancer

• 5-year survival rates by stage:– I: 80-90% (invasive squamous cell carcinoma

remains localized for a long time)– II: 50-65%– III: 25-35%– IV: 0-15%

• ~80% recurrences manifest within 2 years– Recurrences may happen as long as 15 years

after primary therapy

Cervical Cancer

• Diagnosis: – Pelvic exam/ biopsy– CT scan: best method to determine lymph

node involvement• Fine-needle aspiration of suspicious nodes

– IV pyelogram: determine urinary system involement

– Chest x-ray– Barium enema/ sigmoidoscopy

Cervical Cancer

• Treatment– Stage IA1/ limited tumor spread:

hysterectomy– Stage IA2, IB where cancer has spread

over 3 mm past basement membrane:• Radical hysterectomy (uterus, cervix, ovaries,

oviducts)• Bilateral lymph node dissection• Removal of adjacent ligaments (round, broad)

Cervical Cancer

• Treatment– Stage IIB, III, IV: Radiation primary treatment

• Sometimes with chemo as a radiation sensitizer

– If metastases beyond regional lymph nodes or if recurrent nonresectable disease: systemic chemotherapy• Not curative

• Tumor regression occurs in only 25-30% women and is short-lived

Endometrial Cancer

• Most common gynecologic malignancy• Fourth most common cancer in women• Affects mainly postmenopausal women• Peak incidence 50-60 year old women• Less than 5% are under 40 years old • Accounts for approximately 6500 deaths

yearly in US; 36,100 new cases in US/ year

Endometrial Cancer

• Higher incidence in women with:– Increased dietary fat intake

– Obesity ( 3x if 21-50#; 10x if >50# overweight)

– Pelvic radiation therapy

– Family/ personal history of breast, ovarian ca.

– Diabetes (2.8x); Hypertension, PCOS

– Increased exposure to estrogen: unopposed estrogen therapy, nulliparity.

– Late menopause (>52yo), annovulation, estrogen-secreting tumors

Endometrial Cancer

• Spreads:• Via surface of uterine cavity to cervical canal• Through myometrium to serosa to peritoneal

cavity• Via Fallopian tube to ovary• Via blood to distant sites• Via lymph to lymph nodes

Endometrial Cancer

• Precursor is endometrial hyperplasia (occurs during periods of unopposed estrogen)

• The higher the grade, the greater the chance of deeper invasion of myometrium or extra-uterine spread

• Over 80% of endometrial cancer is adenocarcinoma

• Sarcomas approx 5%

Endometrial Cancer

• Symptoms– Vaginal discharge– Abnormal bleeding patterns

• 1/3 of post-menopausal bleeding is due to endometrial carcinoma

Endometrial Cancer - staging

• Stage IA: tumor limited to the endometrium

• Stage IB: invasion of less than half the myometrium

• Stage IC: invasion of more than half the myometrium

• Stage IIA: endocervical glandular involvement only

• Stage IIB: cervical stromal invasion

Endometrial Cancer - staging

• Stage IIIA: tumor invades serosa or adnexa, or malignant peritoneal cytology

• Stage IIIB: vaginal metastasis• Stage IIIC: metastasis to pelvic or para-

aortic lymph nodes• Stage IVA: invasion of the bladder or bowel• Stage IVB: distant metastasis, including

intraabdominal or inguinal lymph nodes

Endometrial Cancer

Endometrial Cancer

Endometrial Cancer

• Diagnosis– Endometrial biopsy or Fractional D&C– Transvaginal ultrasound– CT if metastases suspected– Stool guaiac test if bowel metastases

suspected

Endometrial Cancer

• Treatment– Stage I: surgery

• Hysterectomy• Bilateral salpingo-oopeherectomy• Peritoneal cytologic examination• 50-70% cases no need for post-op radiation• If patient unable to tolerate surgery, radiation

alone used

Endometrial Cancer

• Treatment– Stages II, III

• Additional surgery: para-aortic lymphadenectomy

• If extra-pelvic cancer: add radiation, chemotherapy, and/ or hormone therapy– Hormone therapy includes progestin therapy to induce

regression of tumors, occurs in 35-40% of patients

– Stage IV: systemic chemotherapy

Endometrial Cancer

• Most recurrences of adenocarcinoma of endometrium occur within 3 years of dx

• 90% occur within 5 years

• ERT controversial after treatment for endometrial cancer; do benefits outweigh risk?

Other gynecologic cancers

• Vulvar cancer– 3-4 % of gynecologic malignancies– Average age at diagnosis is 70– 90% squamous cell carcinoma– Risk factors:

• Chronic vulvar pruritis• Vulvar dystrophy• Vulvar intraepithelial neoplasia (premalignant)

Other gynecologic cancers• Vulvar cancer

– Symptoms: palpable lesion during routine PE; may have vaginal discharge/ bleeding if lesion necrotic or ulcerated

– 20% asymptomatic

– Diagnosis: punch biopsy

– Differentials: STI, basal cell carcinoma, condyloma acuminatum, melanoma, Paget’s disease

– Treatment: surgery (vulvectomy), lymph node dissection

Other gynecologic cancers

• Vaginal cancer:– 1% gynecologic cancers– Average age diagnosis: 60– 95% cases are squamous cell carcinoma– Risk factors:

• HPV infection• Cervical/ vulvar cancers

Other gynecologic cancers

• Vaginal cancer– Symptoms: abnormal bleeding patterns,

vaginal discharge– Diagnosis: punch biopsy, wide local

excision if larger lesion– Treatment: surgery (vaginectomy),

radiation

Other gynecologic cancers

• Fallopian tube cancer– Rare– Average age 50-60– Risk factors not well defined– Symptoms: chronic salpingitis, general

inflammation, vague abdominal pain, bloating– Remote history of infertility– Treatment: surgical

Cancer…

A few things to think about1. In the office you may discover a problem or

symptom pointing to possible malignancy such that immediate oncology workup is desirable. How do you word that to your patient without frightening them?

2. What if the patient has already been diagnosed with a malignancy recently, but doesn’t understand the situation or the threat. You have to figure out why they did they not understand. Was it just the shock? Were they not told? What do you say? Suppose they are in denial. How do you tell? How forcefully do you explain? What is your duty here?

Questions to Consider• What do you say when asked, “Can you really

help me?” • What do you say when asked if they should do

chemotherapy or radiation?• What do you say when they have searched and

found some completely off-the-wall treatment?• When do you explain what you can deliver?• What can you deliver?

Talking to Patients with Cancer• There is absolutely nothing routine about conversing with

someone who has cancer, whether it is the first visit or the tenth. There is a certain edginess to the meeting for both the clinician and the patient. Neither of you knows what to expect. Get past that quickly.

• If the diagnosis of cancer is recent, it is easy to start by saying, “That must have been a great shock”. This opens the floor for the patient to start talking.

• The patient has an enormous amount of information for you to acquire about their situation. So along with using your left brain to keep them comfortable, your right brain is getting all the pertinent facts.

• Clarify early on: What are they looking for from you?

Naturopathic Cancer Care• Cancer Situation 1 – patient has elected

standard oncology care (our role is adjunctive supportive care avoiding interference)

• Cancer Situation 2 – after remission from standard oncology care (repair & prevention)

• Cancer Situation 3 – after standard oncology care without hope of remission (repair & aim for life extension)

• Cancer Situation 4 – the patient who declines standard oncology care (aim for life extension)

Basic Cancer Tx Info• 98% of the chemistry in cancer cells is

identical to that of normal cells• Any treatment that affects cancer cells

will disturb normal cells as well• Most cancer cells are more susceptible

to therapies, and the normal, healthy cells are more resilient,

• But there will be side effects.

Common SEs of Cancer Tx (and natural support for them)

• Chemotherapy– Oral mucositis (oral glutamine swish and swallow - feeds

epithelial cells - start preventatively)– Fatigue and Brain fog (acetyl-L-carnitine crosses BBB,

protects brain from toxins)– Neurotoxicity/peripheral neuropathy (vitamins E and B-12

help protect nerves)– Depression (acetyl -L-carnitine 1000mg bid)– Cardiotoxicity (CoQ10)– Cachexia (coconut milk/oil, bone broths)– Nausea (ginger, mint, B vitamins)(Antioxidant therapy stopped during chemo, but given before and after)

Common SEs (and natural support) con’t

• Radiation burns:– Vitamin E 400 IU bid (several days before,

during, and after tx) reduces burning– Fish oil concurrent with radiation– Caffeine on days of treatment– Aloe vera topically

Natural Cancer Tx - MCP• Modified citrus pectin (MCP) - research has

shown it to help prevent metastases and decreases tumor growth.

• Pectin - is a carbohydrate material occurring naturally in food. It provides needed soluble fiber, but is poorly absorbed. When the molecular size of pectin is decreased, it is absorbed. It can bind to the surface of tumor cells and produce the results mentioned above.

MCP• Several products claim to be MCP. Most have little

benefit. Only two are researched to any extent. These are “PectaSol” (by EcoNugenics) and “Fractionated Pectin” (by Thorne Research).

• (Grocery stores may have a pectin product labeled "MCP", which does not stand for Modified Citrus Pectin and is not the same thing.)

• MCP is available in capsules or powder. Powder is best financially, and may disperse better.

• Suggested dosage is one rounded teaspoonful (5 grams) three times daily. Place the rounded teaspoon dose in a few ounces of warm water and stir/shake until suspended and drink.

Natural Cancer treatment

• Anti-cancer herbs• Many mushroom species• Which other Chinese herbs?• Many Western anti-cancer herbs are also toxic,

must be used cautiously and judiciously

Natural Cancer Treatment

• Shen management (from Dr. Fritz)– Counseling– Support from community, family, other

cancer survivors/ patients– Mind-body techniques: meditation, qi gong,

tai chi, yoga– Energy work: reiki, acupuncture (Kaiser

Permenente recommends their oncology patients seek acupuncture)

A word on nutrition and health:1. The Japanese eat very little fat and suffer fewer heart

attacks than Americans.       2. The Mexicans eat a lot of fat and suffer fewer heart

attacks than Americans.      3. The Chinese drink very little red wine and suffer fewer

heart attacks than Americans.       4. The Italians drink a lot of red wine and suffer fewer heart

attacks than Americans.       5. The Germans drink a lot of beers and eat lots of

sausages and fats and suffer fewer heart attacks than Americans.        

CONCLUSION: Eat and drink whatever you like.  Speaking English is apparently what kills you.