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Cancer Screening In Women

Dr. Ranjit Chakraborti

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Cancer is largely a preventable illness. Two-thirds of cancer deaths in the U.S. can be linked to tobacco use, poor diet, obesity, and lack of exercise. All of these factors can be modified. Nevertheless, an awareness of the opportunity to prevent cancer through changes in lifestyle is still under-appreciated. The chance of an individual developing cancer depends on both genetic and non-genetic factors. A genetic factor is an inherited, unchangeable trait, while a non-genetic factor is a variable in a person’s environment, which can often be changed. Non-genetic factors may include diet, exercise, or exposure to other substances present in our surroundings. These non-genetic factors are often referred to as environmental factors. Some non-genetic factors play a role in facilitating the process of healthy cells turning cancerous (i.e. the correlation between smoking and lung cancer) while other cancers have no known environmental correlation but are known to have a genetic predisposition. A genetic predisposition means that a person may be at higher risk for a certain cancer if a family member has that type of cancer. For many types of cancer, progress in the areas of cancer screening and treatment has offered promise for earlier detection and higher cure rates. The term screening refers to the regular use of certain examinations or tests in persons who do not have any symptoms of a cancer but are at high risk for that cancer. When individuals are at high risk for a type of cancer, this means that they have certain characteristics or exposures, called risk factors that make them more likely to develop that type of cancer than those who do not have these risk factors. The risk factors are different for different types of cancer. An awareness of these risk factors is important because 1) some risk factors can be changed (such as smoking or dietary intake), thus decreasing the risk for developing the associated cancer; and 2) persons who are at high risk for developing a cancer can often undergo regular screening measures that are recommended for that cancer type. Information about the prevention of cancer and the science of screening appropriate individuals at high risk of developing cancer is gaining interest. Physicians and individuals alike recognize that the best “treatment” of cancer is preventing its occurrence in the first place or detecting it early when it may be most treatable. Research has determined that 5-10% of all women with ovarian cancer have a genetic predisposition to the disease. This means that women with a family history (mother or sister) of ovarian cancer are at an increased risk of developing the disease. The majority of hereditary ovarian cancers occur in women with a specific genetic abnormality. This is referred to as the BRCA1 or BRCA2 gene, which are located on chromosomes 17 and 13, respectively. Women with the BRCA1 gene have an 85% risk of developing breast cancer, a 60% risk of developing ovarian cancer by age 70 and an increased risk of colon cancer. Individuals with the BRCA2 gene are also at an increased risk. Some studies have indicated that women may reduce their risk of developing ovarian cancer by using oral contraceptives, giving birth to at least one child, breastfeeding and having a hysterectomy or tubal ligation. In women who have a strong family history of ovarian cancer or the presence of the BRCA1 or BRCA2 genes, removal of the ovaries may be effective prevention of ovarian cancer; however, this procedure has not been proven to prevent cancer in all cases. Diet is a fertile area for immediate individual and societal intervention to decrease the risk of developing certain cancers. There is convincing evidence that excess body fat substantially increases the risk for many types of cancer. While much of the cancer-related nutrition information cautions against a high-fat diet, the real culprit is an excess of calories. There is strong evidence that moderate to high alcohol consumption also increases the risk of certain cancers. One reason for this relationship may be that alcohol interferes with the availability of folic acid. Alcohol in combination with tobacco creates an even greater risk of certain types of cancer. High fruit and vegetable consumption has been associated with a reduced risk for developing at least 10 different cancers. This may be a result of potentially protective factors such as carotenoids, folic acid, vitamin C, flavonoids, phytoestrogens and isothiocyanates. These are often referred to as antioxidants. It is important to limit fat intake, as evidence still supports a relationship between cancer and polyunsaturated, saturated and animal fats. Specifically, studies show that high consumption of red meat and dairy products can increase the risk of certain cancers. One strategy for positive dietary change is to replace red meat with chicken, fish, nuts and legumes. There is a rising incidence of cancer in women worldwide and Indian is no exception. The figures are increasing every minute and it is at this conjecture, I think we should talk about it from the preventive point of view so that there is dissemination of authentic information and the much required awareness. We mainly come across the following types of cancer in women: " Endometrial cancer " Ovarian cancer " Cervical cancer.

In endometrial cancer, cancer cells develop in the lining of the uterus. Exact reason for this development is not exactly known, however, scientists believe that estrogen levels play a role in the development of the endometrial cancer. Once a case is reported to us, we conduct a complete medical history and perform a physical and pelvic examination. During the pelvic examination, we try to feel for any lumps or changes in the shape of the uterus that may indicate a problem.

Insulin and insulin-like growth factors may increase the effect of oestrogen on uterine tissue. As all oestrogen exposure is unopposed in postmenopausal women, high circulating levels of oestrogens and androgens in these women is known to increase risk. Being overweight increases oestrogen levels in postmenopausal women and can disrupt ovulation. Pregnancy and parity reduce risk of endometrial cancer by 30% for a woman’s first birth and by 25% for each successive birth. Pregnancy and childbirth are thought to offer reduced risk through the elimination of pre-malignant cells with the sloughing-off of cells during delivery. Evidence suggests that risk of endometrial cancer is 2-3 times higher in overweight and obese women.. Women with highest levels of isoflavenes, found in soya, dried fruit, whole grains and seeds in their diet are reported to have significant risk reductions with a stronger effect in overweight and obese women. Currently, a dilation and curettage (D&C) is the most reliable method for diagnosing uterine cancer. During a D&C, a sample of the cells lining the uterus is removed for examination under a microscope to determine if cancer is present. Following a diagnosis of uterine cancer, additional tests are performed on the cancer cells to determine the stage of the cancer in order to provide optimal treatment. There are several types of uterine cancer, which vary based on their appearance under the microscope. The most common type of uterine cancer is adenocarcinoma. Other variants of uterine cancer that behave more aggressively include serous carcinoma, uterine clear cell carcinoma and mixed type. These cancers, stage for stage, have a worse outcome than adenocarcinoma. Outcomes following treatment of adenocarcinoma can also be affected by the appearance of cancer when examined under the microscope. Doctors grade adenocarcinomas, as poorly, moderately or well differentiated Diagnosis includes the following tests: " Pap Test " Endometrial Biopsy " Dilatation & Curettage " Transvaginal ultrasound

A woman is more likely to be affected if she is- " Over 40 years " Overweight " Take hormones " Infertile " Does not ovulate We would advise her to watch out for- " Blood in vaginal discharge " Abnormal bleeding-other than menstrual flow

Cervical cancer occurs in the cervix, the canal between the vagina and the uterus. This is the most common cancer in Indian women. Cervical cancer occurs when cervical cells grow out of control, typically in the transformation zone. When cells grow out of control, they spread and grow throughout the cervix and may invade and destroy neighboring organs or break away and spread through the bloodstream and lymphatic system to other parts of the body. Cells taken from the surface of the cervix can appear abnormal, but may not be cancer. These abnormal cells, however, may be the first step in a series of changes that lead to cancer. Doctors refer to the abnormal cells as “precancerous”. Precancerous disease involves only the surface of the cervix. When the abnormal cells begin to spread deeper into the cervix, they are referred to as invasive cancer of the cervix. Treatment Options If physicians feel they need more information following an abnormal Pap smear, they may use a colposcope (lighted microscope) to better visualize the cervix or to perform a biopsy, which is the removal of a sample of tissue from the cervix in order to evaluate cervical cells under a microscope. If the doctor cannot determine whether the abnormal cells are only on the surface of the cervix, an endocervical curettage or conization may be recommended. During an endocervical curettage, a small spoon-shaped instrument called a curette is used to scrape cells away from inside the cervical opening. A conization or cone biopsy removes a cone-shaped sample of tissue from the cervical canal. Conization can also serve as the primary treatment of precancerous cervical cancer. A woman is more likely to be affected if she has- " Have sexual encounters at an early age " Have multiple sexual partners " Have poor genital hygiene For these women it is important to know- " Blood in vaginal discharge " Unusual bleeding between periods " Unusual bleeding after intercourse

Ovarian cancer occurs in the ovaries and mainly in older women. Ovarian cancer has the highest mortality rate of all gynecologic cancers. It is the fifth leading cause of cancer death among U.S. women. Currently, the most widely utilized way to detect ovarian cancer is to undergo a complete gynecologic examination at least once per year. Because ovarian cancers begin deep in the pelvis, they often do not cause any symptoms until they are at an advanced stage. In order to improve outcomes for women with ovarian cancer, the disease has to be diagnosed early, before it spreads. It is important to watch out for- " Discomfort in the lower abdomen " Swelling of the abdomen " Loss of weight " Bach ache " Occasional breathlessness

One of the most significant ways to improve survival for patients would be to find a way to screen women for and detect the disease before it spreads beyond the ovary. Currently available methods for screening for ovarian cancer are pelvic examination, serum CA 125 level measurements and pelvic or vaginal ultrasonography. Doctors often perform a pelvic exam on women during their annual check up. Transvaginal ultrasound is also used as a screening tool. In this procedure, a doctor inserts a small probe that produces sound waves in the vagina. The ultrasound waves create an image of the ovaries on a computer screen, enabling doctors to detect signs of ovarian cancer. By adding colour Doppler, doctors can see detail about blood flow in the tissue. In CA 125 testing, doctors look for a chemical or tumour marker called CA 125 in a woman’s bloodstream. Because ovarian cancers usually produce CA 125, an above average level can be an indicator of ovarian cancer. Unfortunately, due to a lack of definitive symptoms, the majority of women with ovarian cancer are not diagnosed until their cancer has reached an advanced stage, when it is considered incurable. For this reason, ovarian cancer has been referred to as the silent killer.. Since symptoms may be discreet and vary from person to person, many women and/or their physicians may not associate the symptoms with ovarian cancer. The symptoms include abdominal abnormalities such as increased abdominal size, abdominal bloating and abdominal pain. Other frequently experienced symptoms are indigestion, abnormal vaginal bleeding, constipation, pelvic pain, urinary frequency or incontinence, pain with intercourse, nausea, fatigue, back pain and diarrhea. It is important to know- " Stage I cancer is found only in the uterus and has not spread " Stage II cancer is present in both the uterus and the cervix. " Stage III cancer may involve the lymph nodes but not the rectum and bladder " Stage IV cancer is the most serious and it means that the cancer has spread past the pelvic region and about to affect the bladder, rectum and other parts of the body.