At your cervix: Whats normal anyway? DR. ROBERT LOTOCKI - - PowerPoint PPT Presentation

At your cervix: What’s normal anyway?

• DR. ROBERT LOTOCKI

GYNECOLOGI C ONCOLOGI ST MEDI CAL DI RECTOR, CERV I XCH ECK

• 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.

Carcinoma of the Cervix

• 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

Disclosure of potential for conflict of interest

• Definition:

– Screening test for:

cervical cancer and cervical dysplasia

– in an asymptomatic

individual with a grossly normal cervix.

What is a Pap test?

Agency for Health Care Policy & Research (U.S. Department of Health)

Conventional Cytology

Sensitivity 51% (CI 37-66) Specificity 98% (CI 97-99)

• 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

Cervical cancer symptoms:



not a diagnosis



symptoms that require further evaluation



uncommon cause of genital tract malignancy

 but must be considered in all patients

Intermenstrual Bleeding (IMB) and Postcoital Bleeding (PCB)

Royal Australian and New Zealand College of Obstetricians and Gynecologists (RANZCOG) Australian Society for Colposcopy and Cervical Pathology (ASCCP)

0.6%

• f women with PCB,

a normal Pap test, and a clinically normal cervix had a cervical cancer

Recurrent Postcoital Bleeding (PCB)

Royal Australian and New Zealand College of Obstetricians and Gynecologists (RANZCOG) Australian Society for Colposcopy and Cervical Pathology (ASCCP)

• S
• me women have no symptoms

 Abnormal Pap test  Abnormal cervix  Acute renal failure

Cervical cancer symptoms:

Carcinoma of the Cervix

• Manitoba: 2004 to 2012

Carcinoma of the Cervix

• Manitoba: 2004 to 2012

Carcinoma of the Cervix – Manitoba

Primary presentation

2004 (N = 53) 2005 (N = 55) 2006 (N = 45) 2007 (N = 47) 2008 (N = 43) Abnormal cytology 21 (39.6%) 21 (38.2%) 8 (17.8%) 15 (31.9%) 18 (41.6%) Abnormal bleeding

PMB Menorrhagia PCB IMB

26 (53.1%)

13 (24.5%) 10 (18.8%) 3 (6.1%)

• 32 (59.2%)

17 (31.5) 6 (11.1%) 9 (16.6%)

• 28 (64.4%)

10 (22.2%) 15 (33.3%) 3 (6.7%)

• 22 (46.8%)

12 (25.5%) 3 (6.4%) 4 (8.6%) 3 (6.4%)

20 (46.5%)

10 (23.3%) 5 (11.1%) 2 (4.6%) 3 (6.9%)

Abnormal Cervix 3 (6.1%) 1(2.1%) 1 (2.3%) Cut thru hysterectomy 1 (2%) 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 1 (2.1%) 2 (4.4%) 5 (10.7%) 2 (4.6%) Unknown 1 (2%)

• Within the 5 year period preceding a

cervical cancer diagnosis:

– Cancer cases had a mean number

• f 17.8 visits/ opportunities.

– Controls had a mean number

• f 18.3 visits/ opportunities.

Cervical Cancer in Manitoba

Rate of physician visits (opportunity to be screened)

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
• f 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

• 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.

The College of Physicians & Surgeons of Manitoba, cont’ d

Complaints Committee, July, 2006

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 clinical diagnosis?

Normal cervix

Normal cervix post-LASER

Vaginal vault uterine recurrence

Endocervical polyp

Cervical condyloma

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

• 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

Pap Test Litigation - Australia

• Factors used to reduce litigation:
• Registry:

Provide screening history Provide fail-safe Routine smear frequency Ensure follow-up of abnormal smears

Pap Test Litigation - Australia

• Factors used to reduce litigation:
• Public and professional education
• Performance standards (ensure accountability,

but will not eradicate mistakes)

Pap Test Litigation - Australia

CIS Vulva CIS Vulva

At your cervix: What’ s normal anyway?

Thank You

• Dr. Robert Lotocki

Gynecologic Oncologist Medical Director