At your cervix: What’s normal anyway? DR. ROBERT LOTOCKI GYNECOLOGI C ONCOLOGI ST MEDI CAL DI RECTOR, CERV I XCH ECK
Carcinoma of the Cervix • Goals: Improve visual recognition to determine a normal from an abnormal cervix. Identify presenting signs and symptoms for cervical cancer. Know when to refer to colposcopy.
Disclosure of potential for conflict of interest • Speaker’s bureau/honoraria: Merck & Co., Inc Society of Gynecologic Oncology of Canada (GOC) GlaxoSmithKline International Center for Infectious Disease (ICID) • Grants/research support: Merck & Co., Inc • Advisory Committee: Roche Pharmaceuticals
What is a Pap test? • Definition: – Screening test for: cervical cancer and cervical dysplasia – in an asymptomatic individual with a grossly normal cervix.
Conventional Cytology Sensitivity 51% (CI 37-66) Specificity 98% (CI 97-99) Agency for Health Care Policy & Research (U.S. Department of Health)
Cervical cancer symptoms: • Abnormal bleeding Between periods (IMB) With intercourse (PCB) Menorrhagia After menopause (PMB) • Unusual vaginal discharge
Cervical cancer symptoms: • Other symptoms: Leg pain (Obturator Nerve Distribution) Pelvic pain Bleeding from rectum or bladder
Intermenstrual Bleeding (IMB) and Postcoital Bleeding (PCB) not a diagnosis symptoms that require further evaluation uncommon cause of genital tract malignancy but must be considered in all patients Royal Australian and New Zealand College of Obstetricians and Gynecologists (RANZCOG) Australian Society for Colposcopy and Cervical Pathology (ASCCP)
Recurrent Postcoital Bleeding (PCB) 0.6% of women with PCB, a normal Pap test, and a clinically normal cervix had a cervical cancer Royal Australian and New Zealand College of Obstetricians and Gynecologists (RANZCOG) Australian Society for Colposcopy and Cervical Pathology (ASCCP)
Cervical cancer symptoms: • S ome women have no symptoms Abnormal Pap test Abnormal cervix Acute renal failure
- Manitoba: 2004 to 2012 Carcinoma of the Cervix
- Manitoba: 2004 to 2012 Carcinoma of the Cervix
Carcinoma of the Cervix – Manitoba Primary presentation 2004 2005 2006 2007 2008 (N = 43) (N = 53) (N = 55) (N = 45) (N = 47) Abnormal cytology 21 (39.6%) 21 (38.2%) 8 (17.8%) 15 (31.9%) 18 (41.6%) Abnormal bleeding 26 (53.1%) 32 (59.2%) 28 (64.4%) 22 (46.8%) 20 (46.5%) PMB 10 (22.2%) 12 (25.5%) 10 (23.3%) 13 (24.5%) 17 (31.5) 15 (33.3%) 3 (6.4%) 5 (11.1%) Menorrhagia 6 (11.1%) 10 (18.8%) 3 (6.7%) 4 (8.6%) 2 (4.6%) PCB 9 (16.6%) 3 (6.1%) - 3 (6.4%) 3 (6.9%) IMB - - Abnormal Cervix 3 (6.1%) 0 0 1(2.1%) 1 (2.3%) Cut thru hysterectomy 1 (2%) 0 2 (4.4%) 1(2.1%) 1 (2.3%) Discharge 1 (2%) 1 (2.1%) 5 (11.1%) 3 (6.4%) 1 (2.3%) Other 0 1 (2.1%) 2 (4.4%) 5 (10.7%) 2 (4.6%) Unknown 1 (2%) 0 0 0 0
Cervical Cancer in Manitoba Rate of physician visits (opportunity to be screened) • Within the 5 year period preceding a cervical cancer diagnosis: – Cancer cases had a mean number of 17.8 visits/ opportunities. – Controls had a mean number of 18.3 visits/ opportunities. Decker, CancerCare Manitoba, 2007
55 y/0 G2 P2 4 month history of heavy PMB and foul smelling discharge What is your clinical diagnosis?
55 y/0 G2 P2 4 month history of heavy PMB and foul smelling discharge Carcinoma of the Cervix
Normal cervix
Normal cervix with IUCD
29 y/o G1 P1 with 6 month history of postcoital bleeding (PCB) What is your clinical diagnosis?
29 y/o G1 P1 with 6 month history of postcoital bleeding (PCB) Normal cervix with extensive ectropion
48 y/o presents for well-woman examination What is your clinical diagnosis?
48 y/o presents for well-woman examination Normal cervix with Nabothian follicles
45 y/o with intermenstrual bleeding for 6 months What is your clinical diagnosis?
45 y/o with intermenstrual bleeding for 6 months Normal Cervix Pap test Endometrial biopsy +/ - ECC
37 y/o GO asymptomatic presenting for well-woman examination What is your clinical diagnosis?
37 y/o GO asymptomatic presenting for well-woman examination Normal cervix
40 y/o G3P3 (3 premature deliveries) What is your clinical diagnosis?
40 y/o G3P3 (3 premature deliveries) DES exposure
34 y/o asymptomatic well- woman examination What is your clinical diagnosis?
34 y/o asymptomatic well- woman examination Carcinoma of the cervix
26 y/o post-coital bleeding for 3 months What is your clinical diagnosis?
26 y/o post-coital bleeding for 3 months Normal cervix with ectropion
48 y/o G2P2 presents with: post-coital bleeding heavy menses no Pap test for 7 yrs past history tubal ligation 2 years ago What do you do?
48 y/o G2P2 presents with: post-coital bleeding heavy menses no Pap test for 7 yrs past history tubal ligation 2 years ago What is your clinical diagnosis?
48 y/o G2P2 presents with: post-coital bleeding heavy menses no Pap test for 7 yrs past history tubal ligation 2 years ago Carcinoma of the cervix
The College of Physicians & S urgeons of Manitoba Complaints Committee, July, 2006 • June 8 35 presents to walk-in clinic with irregular periods with heavy bleeding. • No PV . • Prescribed OCPs to regulate the patient’s periods. • July 12 Presents to family doctor with a complaint of 4 months of abnormal PV bleeding and abnormal cramping. • No complete physical and Pap test for 11 years. • Family MD removed a retained tampon, prescribed A/ B and FU. • FU suprapubic tenderness. No further examination.
The College of Physicians & S urgeons of Manitoba, cont’ d Complaints Committee, July, 2006 • July 31 Attended another walk-in clinic complaining of irregular periods. • No PV . • Prescribed medroxyprogesterone acetate. • October Returned to family doctor with heavy PV bleeding and cramping. • No PV . • Booked for ultrasound.
The College of Physicians & S urgeons of Manitoba, cont’ d Complaints Committee, July, 2006 • Nov 10 Presented to Emergency • PV – large cervical cancer discovered. • Further investigation – metastatic cervical cancer. • Died – Cervical Cancer
The College of Physicians & Surgeons of Manitoba, cont’ d Complaints Committee, July, 2006 • Complaints committee reminds: Complaint-specific physical examination must be performed in a timely basis to address the patient’s symptoms. Physical settings in which the physician works does not alter this requirement. Even if a short appointment is booked, physicians must take the opportunity and make the time to perform necessary examination and tests.
25 y/o G0 asymptomatic well- woman examination What is your clinical diagnosis?
25 y/o G0 asymptomatic well- woman examination Carcinoma of the cervix
35 y/o G2P2 with 1 month history of PCB What is your clinical diagnosis?
35 y/o G2P2 with 1 month history of PCB Carcinoma of the cervix
40 y/o G3P3 with intermenstrual bleeding for 5 months What is your clinical diagnosis?
40 y/o G3P3 with intermenstrual bleeding for 5 months Carcinoma of the cervix
40 y/o post-coital bleeding for 1 year What is your clinical diagnosis?
40 y/o post-coital bleeding for 1 year Carcinoma of the cervix
30 y/o watery discharge for 3 months. Not sexually active for 6 months. What is your clinical diagnosis?
30 y/o watery discharge for 3 months. Not sexually active for 6 months. Carcinoma of the cervix
53 y/o postmenopausal bleeding What is your clinical diagnosis?
53 y/o postmenopausal bleeding Carcinoma of the cervix
What is your diagnosis? clinical
Normal cervix
Normal cervix post-LASER
uterine recurrence Vaginal vault
Endocervical polyp
condyloma Cervical
Cervical condyloma
Endocervical polyp
25 y/o with vaginal discharge for 2 weeks What is your clinical diagnosis?
25 y/o with vaginal discharge for 2 weeks Cervical ulcer
Cervical Ulcer
25 y/o G1 P0 at 20/40 with HSIL What is your clinical diagnosis?
25 y/o G1 P0 at 20/40 with HSIL Decidual polyp
Decidual polyp
Pap Test Litigation - Australia • Versus Laboratory: Failure to detect abnormal cells (false negative Pap test) Failure to report a specimen as unsatisfactory Failure to recommend a repeat Pap test if endocervical cells were lacking.
Pap Test Litigation - Australia • Versus Primary Health Care Provider: Failure to offer cervical cancer screening. Failure to adequately investigate postcoital bleeding Failure to adequately investigate abnormal vaginal bleeding Failure to inform patient of abnormal Pap test
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