Gynaecology: Cervical and Breast Cancer Screening

    Ville Rhetso   Gynaecology is the medical practice dealing with the health of the female reproductive system. The word “Gynaecology” literally means the “Science of Women” and is an integral part of all sexual and reproductive health services delivery programs. Gynaecology is a broad term that encompasses all problems related to her reproductive organs that a woman might experience in her life time. Some common conditions that can be group under Gynaecology are:  

1. Cancer and pre-cancerous diseases of the reproductive organs including ovaries, fallopian tubes, uterus, cervix, breasts, vagina, and vulva
2. Infections of the vagina, cervix and uterus
3. Menstruation related problems such as Amenorrhoea (absent menstrual periods), Dysmenorrhoea (painful menstrual periods) and Menorrhagia (heavy menstrual periods)
4. Infertility or the inability to conceive.
5. Others such as Prolapse of pelvic organs and Incontinence of urine or Urinary Tract Infections.

  CERVICAL CANCER Cervical cancer is caused by the Human Papilloma Virus (HPV), which is the most common viral infection of the reproductive tract. Almost all sexually active individuals will be infected with HPV at some point in their lives and some may be repeatedly infected. The majority of HPV infections resolves spontaneously and do not cause symptoms or disease. However, persistent infection with specific types of HPV may lead to precancerous lesions. If untreated, these lesions may progress to cervical cancer.   Global burden on Cervical Cervical Cancer is the second most common and the fifth deadliest cancer in women worldwide. It affects about 16 per 100,000 women per year and kills about 9 per 100,000 per year. Globally, there are an estimated 530,000 new cases of cervical cancer every year. Of the estimated more than 270,000 deaths from cervical cancer every year, more than 85% occur in developing countries. The high mortality rate from cervical cancer globally (52%) could be reduced by effective screening and treatment programmes.   The risk factors for cervical cancer are:

• Human Papilloma Virus (HPV) - a sexually transmitted virus
• Multiple sexual partners
• Sexual activity in early age
• Smoking/tobacco use
• Immuno-suppressed individuals
• Family history of cervical cancer

The common symptoms associated with cervical cancer are: vaginal bleeding, longer or heavier periods, increased vaginal discharge, bleeding after menopause or during intercourse and pain during intercourse.   Cervical Cancer Prevention and Control Primary Prevention: Girls 9-13 years - HPV vaccination: HPV vaccines are now available in many countries and are recommended to be administered before sexual debut. Girls and boys, as appropriate

• Health information and warnings about tobacco use
• Sexuality education tailored to age & culture
• Condom promotion/provision for those engaged in sexual activity
• Male circumcision

Secondary Prevention: Cervical cancer screening and treatment as needed   Cervical cancer screening Cervical cancer screening is testing for pre-cancer and cancer among women who have no symptoms and may feel perfectly healthy. Screening is highly effective in detecting asymptomatic cases and such early detection is associated with greater survival rates. Women who are found to have abnormalities on screening need follow-up, diagnosis and possibly treatment in order to prevent the development of cancer or to treat cancer at an early stage.   Criteria for Age and Frequency of Cervical Cancer Screening (WHO 2013)

• Pre-cancerous lesions take many years to develop. Therefore, screening is recommended for every woman from aged 30 to 49 at least once in her lifetime and ideally more frequently. The screening interval should be every 3–5 years. Women younger than 30 years of age should not undergo screening except for women known to be HIV infected or living in a high HIV prevalence area.

  Type of screening tests:

• HPV testing for high-risk HPV types: these tests are expensive, time-consuming, and require sophisticated laboratory infrastructure.
• Conventional (Pap) test and liquid-based cytology (LBC): In the Pap test, a sample of cells are collected from the cervix, placed on a glass slide and sent to a laboratory for evaluation. It can take as long as three weeks to receive the test results.
• Visual inspection with Acetic Acid (VIA): In this simple test, the cervix is visualized during pelvic examination, washed with normal saline, inspected, and then washed with a solution of 3-5% acetic acid (e.g. vinegar) and inspected again after 1 minute to identify areas of aceto-whitening suggestive of precancerous lesions by direct vision.

  Treatment: Cervical cancer can be treated by simple surgical methods like Cryo-surgery or Loop Excision at an early stage. In later stages, treatment is through surgical removal, radiotherapy and chemotherapy.   BREAST CANCER Breast cancer is the top cancer in women both in the developed and the developing world. The incidence of breast cancer is increasing in the developing world due to increased life expectancy, increased urbanization and adoption of western lifestyles. For the majority of women presenting with breast cancer it is not possible to identify specific risk factors, however, several risk factors have been documented:

• Family history of breast cancer.
• Prolonged exposure to endogenous oestrogens: early menarche, late menopause, late age at first childbirth.
• Exogenous hormones: Long term use of oral contraceptive and hormone replacement therapy. Breastfeeding has a protective effect.
• Other modifiable risk factors: alcohol use, overweight and obesity, and physical inactivity.

  Global burden on Breast Cancer It is estimated that worldwide over 508,000 women died in 2011 due to breast cancer (Global Health Estimates, WHO 2013). Although breast cancer is thought to be a disease of the developed world, almost 50% of breast cancer cases and 58% of deaths occur in less developed countries (GLOBOCAN 2008). The low survival rates in less developed countries can be explained mainly by the lack of early detection programmes, resulting in a high proportion of women presenting with late stage disease, as well as by the lack of adequate diagnosis and treatment facilities. Breast cancer is more than 100 times more common in women than in men, although men tend to have poorer outcomes due to delays in diagnosis.   Breast Cancer Prevention and Control Prevention: Control of specific modifiable breast cancer risk factors and promotion of healthy diet, physical activity and control of alcohol intake, overweight and obesity. A lump in the breast may be non-cancerous or cancerous and require diagnostic tests such as mammography to confirm the nature of the lump. The signs and symptoms can be seen below: Some of the common non- cancerous conditions are: ✱ Fibrocystic changes: Lumpiness, thickening and swelling, often associated with a woman’s period. ✱ Cysts: Fluid-filled lumps can range from very tiny to about the size of an egg. ✱ Fibroadenomas: A solid, round, rubbery lump that moves under skin when touched, occurring most in young women. ✱ Infections: The breast will likely be red, warm, tender and lumpy. ✱ Trauma: a blow to the breast or a bruise can cause a lump. ✱ Microcalcifications: Tiny deposits of calcium can appear anywhere in a breast and often show up on a mammogram.   Breast cancer screening Screening is the systematic application of a screening test in a presumably asymptomatic population.

1. Mammography: Mammography screening is the only screening method that has proven to be effective. It is a low-intensity X-ray image of the soft tissue of breast which can produce images on a file or on the screen of a computer (Digital Mammography). Mammography is the standard screening and diagnostic technique for breast cancer.
2. Breast self-examination (BSE): There is no evidence on the effect of screening through breast self-examination (BSE). However, the practice of BSE has been seen to empower women, taking responsibility for their own health. Therefore, BSE is recommended for raising awareness among women at risk rather than as a screening method.
3. Clinical breast examination (CBE): It is a low cost approach to breast cancer screening that can work in low resource settings. Clinical breast examination should be provided to any women who detect any change(s) in their breasts that suggest breast cancer. It is recommended that women over 40 are offered clinical breast examination annually.

  Importance of Counselling in gynaecology For all gynaecological conditions, informed and voluntary consent should be obtained from the client, which is free from inducement, coercion and discrimination. Gynaecology is typically considered a consultant speciality but due to poor access to specialist services and apprehensions related to discussing gynaecological problems in public, women often would seek out a counsellor to get information and referral. There may be significant cross-over in many gynaecological problems, for instance, women with urinary incontinence or infections may be referred to a urologist. Some other problems may need referral to obstetric or general surgeons. Thus, counselor role is very important to allay the anxiety and fear of the client, to give appropriate information about the problem and to refer to the nearest gynaecologist.  FPA India provides Integrated Package on Essential Services (IPES) which includes Gynae counseling, screening of cancer through pelvic examination and VIA testing, breast examination for lumps, referrals for further diagnostics investigation, treatment and follow up services.    

Ville Rhetso, compiled this Article and is a Counselor at Reproductive Health & Family Planning Clinic (RHFPC), Nagaland Branch-Kohima