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admin | Category: Herpes Pictures | 16.08.2015
In the low-resource countries of the world, 700 women die every day from cervical cancer, leaving behind families and communities that depended on them.
Most cervical cancer in developing countries occurs in women who take care of children, provide income for families, and work in their communities. Poor women in industrialized countries have a higher incidence of cervical cancer than their wealthier neighbors.
Cervical cancer is caused by human papillomaviruses (HPV).6,7 Safe and effective vaccines have been developed against the HPV types responsible for most of the cancers.
Developing countries need strong and persistent advocates for cervical cancer screening and vaccination programs. Human papillomaviruses comprise a large family of viruses, with more than 100 types known.17 Some types have a high potential for causing cancer (high-risk types), whereas others have a lower potential (low-risk types). While types 16 and 18 are the most common cancer-causing types worldwide, their prevalence varies slightly in different geographic areas.
Normally, the surface layers of the cervix die and slough off, with a controlled stream of new cells constantly forming and pushing upward from below, in a manner similar to skin renewal.
Most women are infected with a high-risk type of HPV at some time in their lives, but, as mentioned above, only a small portion develop cancer. Being faithful to a partner and regularly using condoms are not sufficient precautions for significantly reducing rates of cervical cancer. Cervical cancer can be prevented either by avoiding HPV infection, or by periodic monitoring (screening) for infection and lesions. The most familiar method of cervical cancer screening worldwide is the Pap test, but new alternatives have been shown to be as effective, or more effective, than Pap, often at a lower cost.
Gardasil prevents infection with two of the most common cancer-causing types of HPV, types 16 and 18. Cervarix also protects against infection with HPV types 16 and 18, but does not include protection against any other HPV types. Both Gardasil and Cervarix appear to offer some protection against HPV types that are not specifically targeted by the vaccines (types 16 and 18), mainly against type 31, which is related to type 16. Programmes introduced to prevent cervical cancer should initially prioritize high coverage in the primary target population of young adolescent girls. Once effective strategies have been developed to reach these girls, they can be used to provide additional health interventions appropriate for older children, such as other immunizations, deworming, malaria intermittent preventive treatment, provision of bed nets, nutritional supplementation, and general health and life skills education. Boys can become infected with HPV, they can infect female partners, and they can develop HPV-associated diseases such as penile, anal, and oral cancers or genital warts.
Currently, no therapies are available for active HPV infections, but researchers are working on vaccines that may prevent cancer in women who have persistent HPV infections. Cervical cancer screening of sexually active or formerly sexually active women can determine whether they are at risk of developing cervical cancer. Since its introduction more than 50 years ago, the Pap or cervical smear has been used throughout the world to identify precancerous lesions for treatment or follow-up. A single cytologic screening results in a high rate of false-negatives—that is, it lacks sensitivity and cannot detect many cervical abnormalities, making repeat screening necessary. Efforts to improve the reliability of Pap smears in the last ten years include the development of liquid-based cytology, which uses a small amount of fluid to preserve cells collected from the cervix, rather than directly smearing the cell sample onto a glass microscope slide. An additional advantage of VIA not offered by Pap or HPV DNA tests is that it allows providers to identify the small proportion of positive lesions that are unsuitable for treatment with cryotherapy, a mode of treatment appropriate for limited-resource settings (see Treatment of precancerous lesions below). The success of VIA, HPV DNA testing, and cryotherapy in field settings signals new potential for cervical cancer control in places where cytology programs are not feasible or sustainable.
Accurate information is essential to improving understanding of both HPV and cervical cancer among health care workers, educators, policymakers, parents, and patients.
Because clinicians are often the primary source of information for both parents and adolescents, educating clinicians helps parents to understand the benefits of any vaccine.5,52 Health care workers in many developing countries might not have a clear understanding of HPV infection and its relationship to cervical cancer development and prevention. The relationship of human papillomavirus-related cervical tumors to cigarette smoking, oral contraceptive use, and prior herpes simplex virus type 2 infection. Follow-up study of 232 patients with stage Ia1 and 411 patients with stage Ia2 squamous cell carcinoma of the cervix (microinvasive carcinoma). Cisplatin, radiation, and adjuvant hysterectomy compared with radiation and adjuvant hysterectomy for bulky stage IB cervical carcinoma.
Concurrent cisplatin-based radiotherapy and chemotherapy for locally advanced cervical cancer.
Pelvic radiation with concurrent chemotherapy compared with pelvic and para-aortic radiation for high-risk cervical cancer.
Topotecan has been previously approved by the US Food and Drug Administration (FDA) for patients with metastatic carcinoma of the ovary after failure of initial or subsequent chemotherapy and for the treatment of sensitive small-cell lung cancer after failure of first-line chemotherapy. Topotecan has been evaluated using a daily ? 5 schedule, either every 3 weeks or every 4 weeks, in single-arm studies for patients with cervical cancer that was refractory to or had relapsed following cisplatin-based chemotherapy. A third treatment arm consisting of methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) was closed after 64 patients had been enrolled due to excess toxic deaths.


Patients in each arm were to continue treatment for six cycles or until disease progression or unacceptable toxicity.
Baseline disease characteristics and prior therapy of the study population are listed in Table 1 and are evenly distributed across treatment groups. Cervical cancer is the second most common cancer in women worldwide and the leading cause of cancer deaths in women in developing countries. Among these are the hepatitis B and C viruses, which cause liver cancer, and the Epstein-Barr virus, which is responsible for several forms of lymphoma. Most often, cervical cancer is found much later, usually after age 40 (Figure 2), with peak incidence around age 45 and peak mortality in the late 50s. The cervix is the lower portion of the uterus; it connects the uterus with the vagina (Figure 3). Both pre-cancer and cancer usually arise in the transformation zone, which is larger during puberty.3 In older women, the transformation zone is deeper inside the canal, and the epithelium is not as susceptible to infection. Some lesions resolve spontaneously, but others can progress to invasive cervical cancer (Figure 4).
Women can decrease their chances of developing cervical cancer by reducing some of the risk factors in the list above, but vaccination of adolescent girls against HPV and screening of adult women are the best ways of preventing this disease. It is well-known from years of research that cancer is preceded by these precancerous lesions. Gardasil was 70% effective, and Cervarix 92% effective, against lesions caused by HPV 31 in study participants naïve to that virus. In countries without screening programs, policymakers should consider initiating screening of women aged 30 and older once or twice in their lifetimes, in conjunction with vaccination of girls and young women who are not yet sexually active.15,40,41 To learn more, visit the Screening and treatment section. Routine use of Pap smear screening in the industrialized world has contributed to the 70% to 80% reduction of cervical cancer incidence in developed countries since the 1960s.48 Even in industrialized countries, however, the level of success can vary. VIA involves washing the cervix with 3% to 5% acetic acid (vinegar) for one minute and observing the cervix with the naked eye afterward. A sample of cells is collected from the cervix or vagina using a small brush or swab, and the specimen is sent to a laboratory for processing.
This test is able to detect DNA from 14 cancer-causing types of HPV, with test results available in two to four hours. The affected area of the cervix may be frozen with a cold probe (cryotherapy) or removed using a heated wire loop as a knife (loop electrosurgical excision procedure or LEEP). The vaccines protect against the two HPV types that cause 70% of cervical cancer, but not against those that cause the other 30%. Colposcopy is an examination of the vagina and cervix using a magnifying device with a powerful light source to identify abnormal areas on the cervix and to guide sampling of cervical tissue (biopsy).66 Colposcopy must be performed by trained providers, and colposcopes are expensive.
Pain control for women with advanced cervical cancer is often inadequate in developing countries. Many do not know the cause and burden of cervical cancer and may not be able to understand the value of HPV vaccines or cervical screening for improving the current situation. Based on the results of extensive audience and systems research, all four country programs made the strategic decision to emphasize the protective effect of the vaccine against cancer rather than emphasizing the mode of transmission (sexual activity) or the disease agent (HPV) when educating community members.
As mentioned in the HPV and cervical cancer section above, sometimes people assume that because both HIV and HPV are sexually transmitted, prevention strategies would be similar.
A preponderance of evidence supports a causal link between human papillomavirus infection and cervical neoplasia. In patients with concurrent cervical malignancy and pregnancy, the major dilemma is diagnosis and treatment. Clinical trials demonstrate an increased detection rate of abnormal cervical cytologic specimens. Patients in either group with objective responses and acceptable toxicity were permitted to continue their assigned treatment beyond six cycles after discussion with the study chair. In each treatment arm, over 70% of patients were white and almost half were GOG performance status 0.
In the early 1980s, certain HPV types were identified as the cause of cervical cancer by zur Hausen and colleagues. There is no treatment once a person acquires an HPV infection, but recently approved vaccines can prevent infection if given before sexual activity begins.
Thus, there is typically a long delay between infection and invasive cancer.13,15,16 This is the reason that screening programs can be so effective, as discussed in the Screening and treatment section.
The vagina and the lower part of the cervix are lined with flat (squamous) cells, while the inner surface of the canal to the uterus consists of tall column-like cells.
They first become abnormal (precancerous), and after a time, they develop cancerous properties.
These vaccines do not protect against all HPV viruses that can cause cervical cancer, so screening is still necessary.
If characteristic, well-defined white areas are seen near the transformation zone, the test is considered positive for precancerous cell changes or early invasive cancer.


VIA therefore can be used as a primary screening test or for treatment triage subsequent to primary Pap or HPV testing.
The main benefit is that women are less likely to be lost to treatment because they cannot return to the clinic.47 Screen-and-treat programs have been evaluated in Ghana, South Africa, and Thailand with good results. Conversely, the immunization community may have limited knowledge of cervical cancer and HPV. The women who remain most susceptible to the development of cervical cancer are those who are lost to screening or who do not receive screening at all. When they invade the deep muscle and fibrous tissue, and then the organs surrounding the uterus, the patient has invasive cancer. Because cervical cancer develops slowly, over years, regular screening, along with removal of any lesions, is very effective in preventing invasive cancer.
Rather, cervical screening is the best approach for this group.1,36 Because the incidence of cervical cancer is highest in women more than 40 years of age, screening is especially important in older women (see Continued need for screening below).
According to this thinking, as cervical lesions become less prevalent, technicians will lose their skills of interpreting specimens, so the accuracy of Pap screening will fall.
Widespread use of the Papanicolaou smear has dramatically reduced the incidence of cervical cancer in developed countries. Colposcopy offers direct visualization of the cervix with an opportunity to biopsy sites of abnormality. Particular emphasis should be placed on the pelvic examination, because cervical cancer is often locally destructive before it is metastatic.
The treatment is a matter of concern to many patients because of the risk to the fetus of exposure to ionizing radiation.
Therefore, family physicians must remain vigilant by screening all appropriate women with routine Pap smears.Research is under way to find ways to prevent cervical cancer. From September 2008 to September 2009, 1.4 million doses of Cervarix were administered across the United Kingdom, also with a low side effect rate.
The results are immediately available, allowing treatment at a single visit and thus reducing loss to patient follow-up. Both cryotherapy and LEEP are less radical than the previous standard treatment, cold-knife cone biopsy. A monolayer of cells is then placed on the glass slide for staining and manual screening.16 This technology aims to decrease false-negative results by optimizing the collection and preparation of cervical cells. More generally, the principles of public health screening will help to determine how resources should be allocated in future decades, taking into consideration factors such as vaccine coverage and cervical cancer prevalence. For the missing item, see the original print version of this publication.Close follow-up is necessary in any patient diagnosed with and treated for invasive cervical cancer.
Protein markers for detection of recurrence and vaccines for prevention of cervical cancer are under investigation.
Cytologic screening is recommended at three-month intervals for the first two years after treatment and semiannually thereafter in patients with or without a cervix.33Squamous cell cancer antigen and other proteins specific to cervical cancer are currently under investigation. In 1998, it was reported that 12,800 women in the United States developed cancer of the uterine cervix, and 4,800 women died of the disease.1 Overall, cervical cancer is relatively uncommon in the developed countries of the world, where intensive screening programs are in place.
After breast cancer, cervical cancer is the second most common type of cancer in women worldwide.3Most women with cervical cancer experience a long asymptomatic period before the disease becomes clinically evident.
Identifying women at risk for developing invasive cervical cancer enables physicians to appropriately select patients who require continual screening rather than annual screening. Women who are at risk for developing cellular abnormalities include those who smoke and those with a history of sexually transmitted diseases, human papillomavirus (HPV) infection, low socioeconomic status, two or more lifetime sexual partners or immunosuppression.4 The latter factors cause frequent exposure to potential carcinogens, and their requisite presence supports the hypothesis that cervical cancer is a sexually transmitted disease.
Human papillomavirus infection of the cervix: relative risk associations of 15 common anogenital types. The intraepithelial neoplasia (mild, moderate or severe) is limited to the cervical epithelium. Five-year survival exceeds 95 percent with appropriate treatment.19 Recommended therapy is simple hysterectomy without pelvic lymph node dissection. Both treatments produce similar results, with a five-year survival rate of 80 to 90 percent.19,21 Surgery includes a radical hysterectomy, which involves removal of the parametria, uterosacral ligaments and a 2- to 3-cm cuff of the vagina, and dissection of pelvic lymph nodes.
Oophorectomy is not necessary in premenopausal women.19Radiotherapy involves intracavitary (placement in the vaginal fornices and uterine cavity) and external beam radiation for the treatment of pelvic nodes. The addition of cisplatin therapy halved the risk of disease progression and death.STAGE IIB, III AND IV TUMORSOnce the tumor extends to or invades local organs, radiation therapy becomes the mainstay of treatment.
Researchers found that concurrent chemotherapy with cisplatin alone or with fluorouracil significantly improved the rates of survival and progression-free survival among women with stages IIb through IVa cervical cancer.



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