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MRCOG PART 2 SBAs and EMQs

MRCOG Part 2, MRCOG 2

Course PAID
notes	337
EMQ	1500
SBA	2111

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oncology topic

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oncology topic		Posted by narmin B. Mon Feb 7, 2005 06:36 am
Which strategies would you recommend to reduce the incidence of gynaecology malignancies. Gynaecological malignancies and their reported incidence in general population are as follows: ovarian cancer with an incidence of one in 80, cervical cancer with an incidence of about I%, endometrial carcinoma I in 200. Vulval cancer has the incidence of about one in 300. Vaginal and fallopian tube cancers are rare. In order to reduce the incidence of gynaecological malignancies steps should taken to eliminate risk factors and where possible to establish screening programmes to identify and treat premalignant conditions. Firstly we need to look at the risk factors for developing gynaecological malignancies. These are either genetic or environmental factors. Genetic factors for developing ovarian cancer are history of ovarian cancer in close relatives, BRCA 1 and BRCA2 mutation and non polyposis hereditary colon cancer (Lynch type 2 syndrome). Other factors include nullliparity and use of fertility drugs (for induction of ovulation). Risk factors for developing cervical cancer are smoking, early age intercourse, human papiloma virus infection and oral contraceptive drugs. In the case of endometrial cancer obesity, polycystic ovarian syndrome, hypertension, and unopposed oestrogen treatment and family history of colorectal cancer and nonpolyposis hereditary colon cancer. Vulval carcinoma is associated with risk factors such as smoking, human papiloma infection, immunosuppression and vuval intraepithelial neoplasia suppression increase the risk of developing cancer. Strategies to reduce the incidence of gynaecological cancer include education of the women to eliminate risk factors , screening and appropriate management of premalignant conditions .and prophylactic surgery. Education with regard to the prevention of malignancy should cover all age groups including teenagers. Smoking and early age sex should be discouraged. Barrier contraception method (sheath or diaphragm) should be advised especially for women with multiple partners. The majority of cervical cancers are associated with HPV infection and employing these methods reduce the rate of infection significantly. Collaboration of different groups including health advisers, social workers, and family planning services are required for achieving optimum results. There is an established cervical screening programme in the UK; women should be encouraged to attend for regular smear tests. Abnormal smears and frequent inadequate results should be refereed to colposcopy clinics for further assessment. Premalignant conditions should be treated appropriately. The efficacy of reducing the incidence of cervical cancer with these treatments has been proved in large controlled studies. There is no premalignant stage for ovarian cancer, there fore screening programmes such as annual trans vaginal and Doppler scans, Vaginal examination, measurement of CA 125 every 6-12 months are not helpful in reducing the incidence of disease. However it has the benefit of determining the early stage of ovarian cancer. Nevertheless prophylactic oophorectomy in high-risk group for ovarian cancer such as strong family history of ovarian cancer or confirmed BRCA1 and BRCA2 mutation reduces the rate of ovarian cancer (but not primary ovarian carcinomatosis). These kinds of strategies may have serious psychological and social problems, which should be considered. Also use of combined contraceptive drugs reduces the incidence of ovarian cancer by 40%. In the case of endometrial cancer, change of life style and prevention of obesity, and prevention of prolonged exposure to unopposed oestrogen (in PCOS and Oestrogen only HRT) reduces the occurrence of diseases. Also use of combined oral contraceptive drugs reduces the risk of endometrial cancer by 40 %. There is no well-defined premalignant stage for endometrial cancer. Atypical hyperplasia may develop to endometrial cancer in 30-40. Hysterectomy will reduce this risk. In the vulval cancer stopping smoking and treatment of vuval intraepithelial neoplasia (VIN) especially when it is associated with other risk factors such as immunosuppression and cervical premalignant conditions reduces the risk of vulval cancer. Prevention of HPV infection is also reduce the risk. As vaginal and fallopian tube malignancies are relatively rare conditions, there is no adequate information with regard to the type of measures which could reduce their incidence.
		Posted by Nibedita R. Thu Feb 10, 2005 12:28 am
Endometrial, ovarian, cervical and vulval carcinoma are common gynaecological cancers. Awareness and elimination of the risk factors, identification of the premalignant conditions through screening and their treatment, selective screening for high-risk women, public health education and life style modifications are the important aspects through which gynaecological malignancies can be reduced. Family history of breast and ovarian cancer with BRCA1 and BRCA2 mutation carriers are associated with 30-60% increased risk of ovarian cancer. They need genetic counselling and genetic testing for cancer susceptibility. As the natural history of ovarian cancer is poorly understood and there is no premalignant condition, effective screening for general population is not possible. Serum CA-125 and TVS with colour Doppler alone or in combination may be of value in high-risk women. Prophylactic oophorectomy is beneficial for high risk women although it cannot eliminate the risk of primary peritoneal cancer. General risk factors associated with ovarian caner are early menarche and late menopause, nulliparity with the use of fertility drugs and PCOS with the use of ovulation inducing drugs, though, most of these factors are unmodifiable. Encouragement of COCPs use which is associated with 40% reduction of ovarian cancer in general population, breast feeding, tubal-ligation and hysterectomy (when family is completed) are associated with significant reduction in ovarian cancer in general population. Some endometrial cancers are also associated with certain hereditary syndrome (hereditary nonpolyposis colorectal cancer syndrome-Lynch II). Women with a positive family history can be screened with TVS for endometrial thickness and endometrial biopsy in suspected women, which is highly sensitive for postmenopausal women, although, efficacy in premenopausal women is not known. Prophylactic hysterectomy (when the family is completed) can eliminate endometrial cancer risk and should be discussed. COCPs use reduces endometrial cancer risk upto 50% and should be encouraged, unless contraindicated. Early menarche, nulliparity, IDDM, obesity, PCOS (unopposed estrogenic stimulation), hypertension and HRT of sequential pill are some of the known risk factors for endometrial cancer. Healthy diet, life style modification and use of continuous combined HRT are few measures which can reduce risk of cancer in general population. Through effective cervical screening programme in UK, incidence of cervical cancer has been reduced by >80%. Women should be educated by community and social health services, regarding the importance of regular screening and the awareness of symptoms like postcoital bleeding, intermenstrual bleeding and PMB to be reported early. HPV infection, smoking, early age at first intercourse, multiple sexual partners and immunocompromised individual are some of the established risk factor for cervical cancer. Life style change, use of barrier methods of contraception to prevent infection and enhanced surveillance for immunocompromised individuals for frequent screening can reduce risk of cervical cancer in high-risk population. Screening for HPV in high-risk group and HPV vaccine are under research. If their effectiveness can be proven then incidence could reduce further. Smoking, IDDM, nulliparity and obesity are the risk factors for vulval cancer and may be modified by life style changes. High association with HPV infection and cervical cancer has been established. Women with cancer cervix should be screened for vulval cancer. Lichen sclerosis is associated with vulval cancer in 3-5% cases. Perimenopausal and postmenopausal women with unifocal lichen sclerosis are at higher risk and should be biopsied. Immunocompromised person is at high risk for vulval cancer and should be treated for premalignant conditions. Fallopian tube and vaginal cancer are rare gynaecological malignancy, so screening of the general population is not justified. Regular audit and research to improve the existing screening programme and establishment of new strategy could be of help to reduce the incidence of gynaecological malignancy.
		Posted by Iman B. Sun Feb 13, 2005 09:28 am
By far the most important methods to decrease GT malignancies are a change in life style habits. In case of cervical malignancy, and vulval cancer; the most common association is with cigarette smoking, multiple sexual partners, Human Papilloma Virus infection, and cases who are immunocompromised. This association should be explained to all sexually active females, leaflets and information handouts should be available on these risk factors and distributed to the general public. The recent changes in the cervical screening programme were aimed to decrease extra workload and decrease the false positive rate of smears. Fluid based cytology will obviate the inadequacy of smears, the change in the frequency of the visits for smear taking , every three years from 25 -49 years and then every five years until the age of 65 ys will mean that the at- risk age group are more frequently checked and will improve sensitivity from 74-84%. Ruling out females younger than 25 years old will rule out also the incidence of false positives, this age group have a higher incidence of HPV affection which resolves spontaneously, besides the fact that the incidence of cancer cervix in that age group is very low. An exception to this are those females with multiple sexual partners, and very early age of first sexual intercourse, these can be selected by their GP and included in the programme. Inclusion of HPV testing will increase the sensitivity of the smear result. Population based education on sexually transmitted diseases, importance of using barrier contraception and decreasing smoking is vital. Patients should be encouraged to report any contact bleeding or perimenopausal bleeding, Recently some steps have started towards HPV vaccine for HPV 16 and 18 the major culprits in cancer cervix. In case of cancer of the endometrium, the most important risk factor is unopposed oestrogen stimulation and this should be countered. In cases like polycystic ovaries, or use of tamoxifen in breast cancer patients, where its oestrogen agonist action will cause a state of hyperplasia or Oestrogen patches given to counter the severity of premenstrual tension syndrome. Progesterone should be given in all conditions where oestrogen is in excess or unopposed. In case of hormone replacement therapy, the continuous combined method is safer than the sequential. In case of cancer ovary, there is no cost effective screening programme to date. Known cases of BRCA1 and 2 and hereditary nonpolyposis coli, or those with a strong family history of cancer ovary or breast, can be given combined oral contraceptives, long term use for five years will give 40%-50% protection from cancer ovary and 50% protection from cancer uterus. Prophylactic Oophorectomy is an option to high risk groups, but the risk of early onset menopause with subsequent complications as osteoporosis, must be taken into account, especially in young patients. Cases of vulval lichen sclerosis may have associated VIN or even early stage vulval cancer, suspected areas should be biopsied, and long standing vulvitis or pruritis sent for colposcopic assessment.