Women gynae transcript — SMP305 lecture transcript

See you. Hello everyone, sorry, uh, the clock says suggests that we're an hour early on the back, but that's clearly a lie. So yeah, I'm sorry. I was doing ward round and then clearly the door is locked. So I'm Victoria Parker. I am the suspect registrar in gyne oncology. It's only me here in Sheffield. You are on cases, right? So that means if you don't know, what are you? So you're proper. OK, fine. That's good. Sometimes we give this lecture within that cases block, sometimes not, so that is positive. So you've not done any, so this is your first go, and you're all in Sheffield, yeah? So you will see me around at some point, uh, though I'm doing other things within G at the minute. Oh no. Do I care about that? Not really. So I used to do uh phase 3 with Dad Singh and with lots of focus groups it came about that you don't like didactic lectures or at least your peers didn't. So this is meant to be more interactive. I therefore need you to help me and answer questions, otherwise we'll be here for like ever. Um, so please do your best to interact cos you will get more from it. So cancers in, uh, gynae. Do we know what that is? Cancer of the what? What we're looking at. Cervix, yeah. That is, that's given you a clue actually cos it's, it's told you.

That is a uterine or endometrial cancer. That a bad boy, but they're my favourites. You've made a, that's a, you've made an open midline cut. Can you please where that's coming from. What's the other bit that's attached to your uterus and your fallopian tubes, ovary, and that is rare, but you will see it occasionally. vulval cancer, yeah, and that looks pretty nasty. But some little old ladies sit on that for quite a while and then come in when it gets too painful and then we know you've got it. So what is the most common gyne cancer in the UK? Are we going? So you've told me about uterine, ovarian, cervical and vulva. What are we going with? Who's going uterine. Alright, we've got end of 1. Anybody else wanna join the end of 1? OK. Cervical. Well, it's more popular. Ovarian? Bulal? I told you that was red, didn't I kind of gave you. Alright, OK, so out of all these aren't just gyne, but at the in women breast is the most common by a country mile. Then we've got lung, bowel, uterus, OK, is the most common gyne cancer. And that is about 9000. 800 new cases per year in the UK. And then we've got ovary, which is around 7600. And then off that slide, cervical's only 3300, so that's not very many. Vulval only 1400, and then you can also get a cancer of your vagina, which is very rare, but we in Sheffield are a, you're quite, I suppose you're lucky in some ways because we are the tertiary cancer centre. So how it works is you're, you're all in Sheffield, you said, aren't you? You're not, no, some of you are elsewhere. So if you're in Barnsley, Rotherham, Doncaster, you might be in Bassett Law, um, Chesterfield, all the cancers come here with ovary. All the cervixes come here. They can operate on low grade endometrial cancers, but and ovaries that we don't think are cancerous, but everything else comes here. So if you're in Sheffield, you'll see more. Bulk I suppose, but it's, it's more niche um and you'll see all the vulv and vaginal cancers as well because they all have to come centrally. So if you look at the 20 most common cancers in women and look at the rate, the incidence, uh, comparing between 2079 versus 2017 to 2019, all cancers are overall increasing in women. Womb cancer, uterine cancer is increasing by about 9. 10%.

Any suggestions why contraception contraception contraception, it, I mean it could be. I mean I think HRT is getting better unopposed oestrogen is a risk factor, but I think generally most GPs now are, you know, trying to, you know, are pretty up on that now. What, what, what is everyone? Becoming. Older, yeah, and obese. I think there is, we have much higher rates of obesity now, don't we? And uterine cancer, some unfortunate ladies get it and they're thin, but it is generally a disease of being overweight or obese because your fat cells convert androgens to estrogens and that stimulates the uterus, the endometrial lining to get hyperplastic and then it. Converting into a malignancy and the ladies that we operate on um I I like we've got a lovely lady now but she's BMI is 70 and she's 27 and she's inoperable because we can't actually we tried to MRI her and we couldn't ventilate her even lying flat so we can't we it needs to be keyhole because what instrument could get through fat that hip. So it tends to be obesity, um, ovarian cancer's gone down. Could be hormonal contraception suggestion because we're suppressing ovulation, suppressing the number of cycles the ovary goes through with ovulation, reducing the risk of damage DNA damage that's possible. Any other reasons why ovarian cancer is going down.

I think, I think we're more aware of it now, aren't we? I think there are more perhaps more campaigns talking about the symptoms of ovarian cancer though as we'll go through they're very vague. And the other thing that you might not know about is in the past when I was training, when people used to do hysterectomies for benign disease, we used to just take away the uterus and leave the tubes and ovaries and now there is this big vogue to take away the tubes at the same time as the uterus. Even in benign disease because we know ovarian cancer and primary peritoneal cancer can start from the tubes very often in things called stick lesions, serous tubular intraepithelial carcinoma. So we take the tubes now much more and benign gynaecologists are doing that all the time. So that's changed in my lifetime and my training, um, and you will think it's just routine now and you'll see that. The other thing I think is BRCA. So that's come about now we've screened, we're much more aware now, aren't we, of BRCA1, BRCA2, these genes that increase the risk of breast and ovarian cancer and people now undergo risk reduction surgery for that, OK, to remove

tubes and ovaries. And my boss Mr. Gillespie, he does those, he's the guy who's the family history lead and people come to him for that. And then interestingly, cervix cancer's not changed, that's really interesting, but we'll come onto that and. Talk about vaccines shortly. So this is your chance to shine. OK, Swan, um, cos I wanted to get you thinking cos it's boring just sat there. 62 year old goes to her GP with postmenopausal bleeding her vagina. You're the GP. What you're gonna ask her. Family history? Sorry, family history. Yeah, family history. So what are you, what are you thinking in your, where are you going with that? Is it cervical and. Yeah, so there could be. So my top one, because I'm now at this point, I remember being at your stage and it's really weird to be at this stage now because I thought, oh my God, I'll never be here and now I am, and I wish I wasn't because it means you're getting older. But now I'm focusing, I'm in my head, I'm like, is this a genetic, is it Lynch? Is this a, a family history of uterine cancer? So that's what I'm going for straight away with that, but you're right, other gyne cancers are re.

Relevant. Anything else you're gonna ask about the, the bleeding? When did it start? Yeah, when did it start? Because some might have just had one spot and they're straight there, and that's great. And I know that that will usually be somebody with a grade 1 stage 1 cancer, whereas if it's been a year, they could actually have stage 34 disease. So it just gives you a rough idea of what might be going on. That doesn't always correlate, but it's a good, good thing. To ask about anything else? How much? How much? Yeah, so how are you gonna, they'll just, oh it's a lot, doctor. What are you gonna or it might be not very much, doctor, and then you need to push them. So how are you gonna push them? You're right, open questions first, but then sometimes it doesn't work. Yeah, how often are you changing your pads? So is it every What if they say every hour, that's that's a fair amount, isn't it? Or every half an hour, twice a day, and then you can say, you know, like you do in your general gynae history, are you needing to wear tampons and pads? Are you flooding all on the bed? Do you have clots. So all of this needs to come out, or is it just on wiping? And then the little old ladies, it's not very nice, but is it coming from the vagina or is it actually rectal bleeding? You've always got to have that in the back of your mind because it or or is it urinary. UTI or renal stones, so you've gotta, you've gotta try and work that out. So ask about urinary symptoms, bowel symptoms, that's relevant as well for those reasons. Anything else this might be associated with? Not always, but having that dryness? Dryness like postmenopause, yeah, exactly. So this could be, that's a good point, that could be it could be something like, uh, vulvovaginitis, so like, you know, postmenopausal. Changes of the vulva vagina, they could have bleeding just from that and they need some oestrogen if that's not contraindicated or moisturised. That's, that's good.

Anything else? Recourse? Yeah, recent sexual intercourse because you're thinking of in correctly so like your general gynee history, aren't you like STIs. These general generally tend to be slightly older, but you should ask about it and your, you know, your STI. History that is important. Pain is another one, not always, but if you're thinking they've got an advanced cancer, they might have pain so then you go through your Socrates history or dyspreunia, you know, pain on having sex and is it superficial, is it deep? If you think they might have a cancer, what else do you get with cancer? Weight loss weight loss, yeah, again with uterine that would be a very late stage and these tend to present pretty early actually. We're lucky with you right, uh, and people are pretty hot now on postmenopausal bleeding, but yet weight loss is a good one. If they've got advanced stage 4 disease they get breathless cause you get chest mets, um, and chest pains, so you should really ask about it. It again advanced disease, they get, uh, leg swelling because it's all in the lymph vessels. So I suppose that's how you, but I'm thinking of cancer because that's what I'm trained to do, that's what I see, but you should be. Much more broader. So we're worried about endometrial cancer because that's why I'm here clearly. Uh, what are you gonna do? You're gonna say watch it, come back in a bit.

No, get out of my room and send her where? Yeah, it is a 2 week wait essentially. So you're gonna send her off. Now this is just for your knowledge, I think it's quite useful uh for you to have this in your head generally because people are ban, you know. Put all these terms about and you'll be sat there going, what the hell are they on about what does it mean? Um, so we have this in the UK we have a 28 day faster diagnostic standard which means that we in the hospital should be ruling out cancer or telling people that they have the cancer within 2428 days of that referral from the GP. Now that is tight actually because think about you've got that referral time that's dead and they've got to have the scan and it's gotta be. Interpreted then they've gotta have a biopsy probably then they've got to come to clinic, maybe more imaging. So that is actually quite difficult to say yes or no within 28 days. And then we have 3162 which you must have heard of in other cancers if not this one. So if we do this first, so from that GP referral we should start treatment within 62 days. Again that is tighter than it sounds. And when we've decided that they've got a cancer and we, we want to treat and they're fit enough to treat, we should start that treatment within 31 days. But these, they're not as easy and often, particularly, I don't, I mean I trained in Cambridge, so everyone was quite well off, affluent, fit, generally. Here, different ball game, right, so everyone here. I tends to be or not everyone but a lot of patients tend to be overweight, smoke, um, deconditioned really and to put them through what we're gonna put them through, you can't without things like rehabilitation. I don't know whether you've heard of that, so it's like optimising patients for surgery and getting them fit to go through what we want. Cos it's not just about operating on them, you've gotta get them, you know, off of critical care at home cos that's the aim, you don't want them to be in critical care for the rest of their days. So risk factors for cancer of the uterus. Shout some out. We've said some haven't we?

Obesity. Yeah, obesity is the big one. Smoking does, I haven't got it on there but it probably does cos it does yeah it does increase er your risk of er DNA damage. Uh anything else? Yeah, oestrogen exposure so that might, might be unopposed HRT. It might be cos you said obesity. Family history of Lynch, which I'll talk about cos you'll probably think what's she on about? Um, anything else? It's not having children. Yeah, nulla parity is one, that's right. So having kids is protective. um, so similarly nulla parity and uh late. Menopause or early menarche, they're, they're things to look out for. Uh you can also get, as have you heard of like ovarian tumours like granulosa cell tumours that can secrete oestrogen and they can cause cancer of the uterus as well. So always think of that it might not be the uterus that's the problem, it might actually be an ovarian lesion, uh. Diabetes also increases the risk and interestingly liver disease because again it's all to do with so diabetes and polycystic ovarian syndrome are all to do with insulin resistance um and they they increase the risk of ovarian cancer because essentially you have um you have deficient. oestrogen metabolism and higher rates of sex hormone binding globulin then gets converted to oestrogen um similarly with the liver disease you basically get higher levels of uh androgens and

estrogens. OK, and that is largely unopposed, so Lyn I don't know if I've talked about Lynch there but I will mention it in a minute. So types of endometrial cancer, so there's, I'll tell you cos you might not know, but there's type 1 which is endometrioid, and type 2, which is non-endometrioid. Do you know which one's the most common? Take a guess. 1 or 2? Yeah, it is. So 10, hang on, I've gone rogue. 1 is the most common, uh, 80-90%. And the most common type of that is an adenocarcinoma. So if you're ever stuck in an exam, go with it's an adenocarcinoma. There type twos are much rarer. So you know you've got adeno squamous squamous papuris, clear, clear cells associated with what niche question, but it might come up and nice one, you know it. Clear cells associated with what other gynae condition that is poorly investigated, poorly diagnosed, people suffer for ages with symptoms. Huh? No, not vulva, a benign condition. PC POS, no. It's been in the news. Endo. So clear cell can come from endometriosis.

Not common, but it can convert. Sarcoma's generally nasty. Nasty buggers, hard to treat, chemo refractory, radiotherapy refractory progress fast. And then we've got Lynch, so that's an autosomal dominant condition. It's real name is ridiculous. It's hereditary nonpolyposis coli, I think there's another scene in there and it's associated with bowel cancer as well. Um, one in around 300 have Lynch in the UK. Most don't know. So that family history is is important because it's coming now cause now since 202,020, 2021 in the UK, all womb cancers we look for Lynch mutations now, but we didn't before. And then if we find one, then we. Test, we test the tumour first, and then we test the woman and then obviously that goes on to family history, screening if it's positive, but 3% of our womb cancers are due to Lynch. So now we test, but it's the main, one of the main risk factors with it as well is bowel cancer. It is also associated with ovary cancer, yeah. Is that that 1 in 300 people have the gene?

Yes. Yeah. And there's about 6 gene mutations um that we look for in a panel, um, that it's basically um hypermethylation of 6 genes. It's really interesting. OK. So you've now got, you've you've got that patient back cos you've now morphed from a GP into a gynaecologist, but you're a fast track gynaecologist, so they come to these fast track clinics where they see a a gynaecologist trained in cancer management, so like the people that you'd see in the district generals, this is like our district general service in a tertiary centre. So they're not gyne oncologists like me, they're general gynaecologists with interest in cancer. So what tests are you gonna order? So we've got one with postmenopausal bleeding GP centre. What tests? Transvaginal. Yes, a transvaginal ultrasound is the is the number one and a transabdominal because you don't want to miss an ovarian lesion. That's causing that problem and there have been many cases and will continue to be cases of where you've just done a vaginal scan and you miss, it's really embarrassing like a gigantic pelvic mass, OK? So if you take nothing home from today aside from investigations, always feel people's abdomen because you do. You look a bit of a, of a, I won't say it if you miss a giant mass, but you've done a lovely pelvic exam, but that they've got, you know, I mean hopefully you wouldn't, but some ladies, our ladies look really pregnant, but you don't wanna miss a mass coming up to the umbella because they're all fat, so it's not, you know, it's not impossible. So feel their abdomen and transvaginal, transabdominal ultrasound.

I think that's probably all you you want to do at the minute cos I'm gonna talk about this, so I'll talk to you about that first. So this is your ultrasound, so this probably looks slightly strange, but this is your uterus, hang on, let me get myself going in here. Yeah, there's your uterus, that is your uterus. Uh, and that is the endometrial thickness there which is really what we're interested in, and it's 12. Is that right? Who thinks yes? Yeah, I agree with you, yeah, that's raised. So if they're not, if it's greater than equal to 4 millimetres, we should be biopsying them, OK? If they're on HRT, we give them a bit more and we say more than 7. And if they are more than 10, they should really go straight to a hysteroscopy clinic because. They might have a polyp there um or a fibroid in the in the cavity that actually needs resecting rather than just biopsy. So I've told you the next investigation, which is a biopsy, which have you heard of a Papel biopsy? We some of you have. It's like a, it is like a pen and the middle section comes out like a straw and then you move it up and down and it's suction and then the tissue goes in the tube. And then we squirt it in the pot and send it off for histology. It's uncomfortable, um, not terrible, but patients don't, you know, they go, don't tend to like it that much, um, but it's very tolerable in the outpatient clinic. Um, that is a quick thing you can do. Oh, hang on. Any other imaging? So what if we know now we've got a cancer of the womb? Any other imaging?

Go on, I heard some muttering, yeah, of what? Yeah, I'll take that, but it pelvis, so MRI pelvis is what you want to know because you want to stage the cancer now, so stage is spread, so patients get confused with this grade is stage of like grade is the cellular abnormalities. Remember stage is spread, so MRI is staging the disease, so we want to. Stage 1, stage 234, I'll show you that in a minute, but you don't need to remember that. No one's ever gonna ask you that in an exam, that's MRCOG question. But yeah, pelvis MRI, anything else? So we want to do a chest x-ray usually just to check they've got no chest disease and that's normally enough. But if you've got one of those type 2 cancers like a squamous or a clear cell, we'll do a CT because they are much more common to have lung mets because they're more aggressive, they're more abnormal, but your bog standard, which is 89% of what you'll see is adenocarcinoma, we just do a chest x-ray, OK? We'd also do a CT chest abdomen if you've got advanced disease, um. But most haven't, and the surgery we do is a hysterectomy, so we take out the uterus and cervix, no gyne oncologist leaves the cervix behind. It really upsets us if we're wrong. And we may need to sample some lymph nodes to check the spread. You might have heard of sentinel lymph nodes now, so they're the first lymph node that is drained by the endometrium, and we can sample those rather than do a full lymphadenectomy because you get lots of leg swelling with that which patients. Reasonably don't like. So surgery is an option for low stage diseases, higher stage like stage 34, radiotherapy really. And that can either be brachytherapy where you put a rod in the vagina and give local treatment to the top of the vagina or it can be external beam where you fire radiotherapy at the whole pelvis. So that's the highest stage disease, BRCy is more. Um, usually for our stage ones that have involvement of the lymph or vascular space just to reduce the risk of local spread. Anything higher than that needs external beam. Higher stage disease chemo. But also we've got this with endometrial cancer, we've got progesterone therapy. So we give high doses of progesterone to ladies that we're either prehabilitating because they're not fit to operate on or ladies who are 90 have come with it. Because increasingly people are biopsying we're investigating more and they're not fit for a haircut, quite frankly, let alone doing this on them. So we stick them on progesterone, but we give them, um, high doses, so we give 200 milligrammes a day of progesterone which freaks out any benign gynaecologist because they give like 10, 3 times a day and we give proper doses, but it does increase your risk of blood clots on the lung and leg, heart failure. Your diabetes, so we have to be a bit careful, but that is our treatment.

Uh, I just think this call, cos some of you might see, come and see us doing it, so I do the robot with Mr. Gillespie. Uh, this is great cos have you ever seen any robotic stuff? Yeah, in what urology or. Oh cool. So we, we sit on the console and then the patient's here with all these laparoscopic instruments so it's. Like minimal access surgery, but we aren't stood by the patient. We're in the console and there's a, an assistant who's by the bedside. It's great for really big ladies because I can't tell you, it kills you like leaning over a woman with a BMI 55 for two hours, you are trashed and I'm not tall, you know, it's, it's difficult, whereas that is a career saver, so I quite like it. And a back saver to keep me going till I'm 70. Which is clearly how long I'm gonna be. So stage, uh, briefly, so stage ones, just so you've got it in your head roughly, are in the lining of the womb or under 50% into the myometrium. Stage two's go over 50%, stage 1B's sorry, go over 50% in the myometrium, but these are local tumours and I would say vast majority are like this that we see. Stage two start going into the cervix. 3 start going into either the ovary, vagina or into those lymph nodes. And then 4As we're going into bladder and bowel and then at 4B we're going elsewhere. But endometrial tends to present early. Survival, pretty good, look 92%. The stage 1, which is where most of ours present.

OK? Anything you want to ask me about endometrial? That's what you'll see a lot of. The district generals will operate on the stage one A's, grade 1 to 2s. Everything else has to come here because we have to sample lymph nodes and they don't do that yet in the district generals. Do you get any common symptoms with women presenting with endometrial cancer aside from unexpected bleeding? Bleeding is the main. Main one really that is the, the top whack is postmenopausal bleeding, yeah, irregu so unscheduled bleeding on HRT is the other one we see, um, but most of that is fine. It tends to be the postmenopausal bleeding that is the the usual one and women on tamoxifen. And as well they're at much higher risk and I feel that the breast team don't often tell them that um you've gotta be really careful, yeah um what's the clinical sort of benefit of approaching between type 1 and type 2 it's just so for us it's I suppose surgery wise you do different things so if it's a type 2. To the cancer centre, so they'd never be operated on by district general because we do lymph node sampling because they're much more likely to be more aggressive to spread um we'd also do CTs because they're more likely to be everywhere else and they would get adjuvant treatment. So with endometrial cancer, the, the hallmark really or the number one is surgery to remove the uterus, but the type twos tend to need adjuvant treatments that's. Post-surgery treatment with chemotherapy, radiotherapy, so it, it does determine your what happens, whereas your type ones if you've got an adenocarcinoma, it's a stage one A surgery is all you need, then you're followed up. 1B's may be offered brachytherapy but nothing else usually, but if you've got one of those rare types you'd need chemo chemo rounds, yeah. I hope you do surgery as well as. Piotherapy. Uh, so for stage 3s we they are difficult. So if you're symptomatic and you've got it in the lymph nodes, so you can operate, but the point of surgery is to clear the disease and to achieve clear resection margins. So you can, if you've got a big uterine mass and you're having torrential bleeding, yes, you could do a hysterectomy for symptomatic benefit, but. If you've got lymph node involvement, you are kidding yourself if you think you can just do a lymphadenectomy and that's it, because it will be higher up the chain, it'll be in the periaortics, it'll be elsewhere. So you know they're gonna have more treatment and the morbidity tends to increase when we do a massive operation because that would have to be open surgery with full lymphadenectomy, probably a radical hysterectomy with which I'll talk to you about in a minute, taking more than just the uterus, you're gonna need more fluffy. Around it and then they're gonna have chemora. So I saw a lady recently who was asking us who's had chemoAD and then said could we do surgery to take the residual disease but there's no prognostic benefit. But for symptomatic control you can consider it if they've got a big uterus bleeding everywhere, but you're not gonna clear it really. And one mode of treatment is usually better than multiple.

Yeah, but that then that's a good question. Same as like some gyne oncologists, I think we're quite, I would say quite sensible in in Sheffield, but like for ovarian cancer, some gyne oncologists in old ladies will take paraaortic paracardiac nodes out surgically. I mean, you're not gonna clear it, are you, because you've clearly got more lymph spread. They're gonna need chemotherapy. And come back. What is the point of doing a massive thoracotomy on an old lady? It's, you've gotta have some sense, I think. Surgery, just because you can do it doesn't mean you should do it. So are we all right with endometrial? So we're on surg uh cervical now, which is interesting. So gynae, as you've probably worked out, is full of, well, you will work out. OBS is another ball game. Abbreviations. We talk in code. IMB? I know. Intermenstrual bleeding, PCB? Postcoital bleeding and then pelvic pain. So you're the GP, so your sexual history was good there because all of these could be an STI. Yeah. So what you're gonna ask just quickly throw some things at me. Family history, yeah, family history of.

Cervix cancer causes some, some families just don't have smears at all, which is interesting. HPV, HPV, yeah, so if they've been vaccinated, that's good. All of you lot will cos you're like dead young. I sadly was too old. You want to know about like how long the bleeding's gone on, don't you? How long has this been similar to what you said to me before, how long is this a one-off, is this every time? what it what it's like. Ask about the pain with your Socrates. Anything else? Menstrual history? Yeah, menstrual history, that's good. Systemic cancer symptoms. Yeah. Systemic cancer symptoms, perfect. Dyspunia again, bladder, bowel symptoms. And then you'd also obviously go through past medical history, past surgical history, you know, your meds, your allergies. And social history, all of this cos what you're working out, I mean what you should do in GP I mean I'm working out whether we they're fit enough to operate, that's all I'm thinking about is can we operate on you? Am I gonna kill you by doing it? But as a GP also think it's not in this case cos she's young, but think about whether they've got capacity to consent to treatment. I think we've seen that a bit more actually that some GPs just refer, you know, and actually they haven't. capacity to understand and we should be having things called best interest meetings in the community to to think about what does that patient want? Is it in that patient's best interest to send someone who's in a care home to hospital to have all these tests done that they don't want and they find really distressing and the family don't want. You see what I mean? so always think about that. Do they have capacity, do they want all of this done? I mean, most will. Clearly, but just think about it.

So what, what are you worried about? Cervical cancer, yeah, in this one, and you're gonna, what are we gonna do? Send her? 2 week wait bye bye. So this is a bit difficult because it's blown up and I don't think that projected us me any favours, but that is a cervix that's being looked at under um we do colposcopy, so they come. Well, they might not actually. Some cervixes will come straight to colposcopy where we look at the cervix with a microscope and you get a like a blown up picture like that. Some will just come to fast track and we'll just do a speculum and have a look at it, cos sometimes it's pretty obvious. Oh, the other thing you should ask about though is discharge. So any abnormal vaginal discharge, any change in smell, colour, things like that. Cause some ladies all. Get is discharge and advanced cancers smell like BV, you know, bacterial vaginosis, that really fishy metric, and you can smell. I know whether a woman's got an advanced cancer when she walks in, because they just get this profuse discharge that's clear and really fishy smelling, and you know what you're gonna find before you even put a speculum in. So that, believe me, is a cervical cancer, just go with me on that, OK? So. You've confirmed that, so what are you going, oh, risk factors for cervical cancer.

You've mentioned HPV is the God, yes, good. I'm glad that came up first. HPV is the driver of cervical cancer. Um, so missed vaccination, yes. What comes with HPV? What is, what are we thinking the risk factors. Yeah, multiple sexual partners. Anything else? STIs would come with that wouldn't it? Unprotected sex or risky sexual behaviours, drug taking, um, anything else? Sorry love, look at my. Yeah, combined pill, because you're less, I don't think it's the, well, some people think the combined pill increases the risk in itself. Evidence is a bit dodgy, but it's essentially cos you're less likely to uh have protective contraception because you think, or barrier contraception because you think you're on the pill, you don't need it. Any other things that you're thinking about viruses? What makes you more likely to get a virus? Yes. If you're immunocompromised, so if you're HIV positive, but also what about all these women on, uh, DMARDs, so disease modifying therapies like methotrexate, increasingly people are on all these MBs, you know, whatever they are, pembrolizumab in in like MS or dermatology, everybody's on a map now, aren't they? These massively suppress your immune system, which means you are less likely to clear your. HPV virus, it's more likely to persist, and we know that persistent HPV causes CIN so that's precancerous cervical lesions, cervical intraepithelial neoplasia, and then ultimately a cancer.

OK? So like you've said, missed vaccines, uh, early age of having sex, multiple partners, STIs. Previous CIN immunosuppression, OCP and cigarette smoking, that is a definitely this one because you you're more likely to cli cling onto that HPV and not be able to clear it. So as you've told me, HPV is the god. um, the ones, not all HPV is bad, but you know it's also associated with oropharyngeal cancer as well. 16 and 18 are the main drivers, so what we're worried about is high risk or oncogenic cancer causing HPV subtypes, 16 and 18 are the main ones, but all of these are oncogenic HPV types. And do you think all of those are in the vaccine? No. Whose idea was that? So not all of those are in the vaccine that you guys have had. So there's what, uh, hang on. And 80% of the population will come in contact with HPV at some point. That's mad isn't it? Some up to 90%, so pretty much all of us here are exposed. So this is the vaccine that some of you may have had that came in 2019. When did you last have your vaccines? Was it before then?

Yeah, probably was, wasn't it? Yeah, so the Gardasil 9 has those 9, different vaccines, different oncogenic types here, but they're not all for cancer. There's some for warts, uh, like 6 and 11, but there's lots there that you can see. We started vaccinating with HPV in for girls in 2018, but do you know when we started with boys. Boys were much later with HPV vaccine. Again, this is crazy. It wasn't till 2019, I believe that boys were vaccinated, which is mad isn't it, because it, you know, they are half the population and it is a sexually transmitted disease, so it's really awkward at. Patients come to clinic and they're like I've been with the same partner forever and I was always HPV negative and you're like yeah. Somebody's been playing away. But you and you can see it realising and you but you can't. That is what's happened essentially or they've had a reactivation if I'm being really kind. Could be one or the other. So before the Gardasil 9 was introduced in 2019, but

before that we only had the Savarix, which was 2016 and 2018, so we only did 22 oncogenic types prior to that, and then we had a quadrivalent one with 4. But only since 2019 we have we been doing nine, and it's interesting because. I don't know if I can show you. The, I might be able to say, but we're not monitoring in the country like which types of HPV are most prevalent. We just vaccinate, but it will change, won't it, over time, if you think about like the cold, coronavirus, things mutate and different serotypes become more prevalent. So there may be a time where these oncogenic types are not what's circulating. Anymore because we've got rid of them, but we aren't actually monitoring that, which is that will come in your lifetime and my lifetime that we're gonna have to modify this by actually checking which serotypes of HPV people are having when they have cancers and when they come for their smears because we we're not, we just check for 1618, and other, that's all we get reported. So that is a bit of an error. That will need to be changed at some point. What percentage of cervical cancers are preventable?

I'll give you some options. It's not gonna tell you the answer, is it? Right, 60.7%, 85.1%, 94.6%, 99.8%, what are we going with? Who's going for one? No. 2. OK. 34. The sole, the sole person there I think at the back. So the answer is 99.8% are preventable. That is crazy, isn't it, if you just vaccinate. So this is a real, this is one where we can have a really good effect with public health. Um. So just for interest cos uh again this is not the company in your exams but it's just interesting to look at national data. So well this is our Yorkshire data, the South Yorkshire Cancer Alliance. In girls under 25, we have had no cases of cervical cancer since 2020 at all in the region. So 2020 was the first year that the vaccinated cohort hit the national screening. programme. So it is working, clearly, and this is replicated all around the country. So look, before we were getting anywhere between 5 and what's that about 13 cancers a year, but none, and it's the same again this year, last year in 2025. But most people in the screening programme are not vaccinated. Because we've got some in that 25 to 35 age group, but after that, no one's vaccinated, so most aren't. So this is why. That graph initially I said cervical cancer rates aren't changing. This is why, because most are not vaccinated, OK?

What are we on to now? So, so now you're the gynaecologist. What tests are you gonna order? So if you've, you've got, you know they've got a cervical cancer. You might have done a biopsy on that actually. If you've got a big mass on the cervix, I would biopsy it because you want to know what type it is because again that's gonna affect adjuvant treatment, what we do, what images. So you'd have biopsied it, but what other tests? You could do an ultrasound. We, we usually go to your second option first, MRI pelvis, yeah, because you want to see about the spread of disease. Any other imaging? If I tell you chest x-ray is not enough for this one, CT of. Yeah, chest, abdo, pelvis, cos you want to know where this has spread to, OK? And sadly we are seeing a lot of ladies now. These tend not to come with stage one disease. These guys tend to come with advanced disease. So the ones we pick up in the screening programme tend to be early cancers, because that's screening, isn't it? We're trying to pick up early cancers, but the ones that just walk in with what we said on there, intermenstrual, postcoital, pelvic. Pain they have advanced cancers and we have had a flurry of ladies who are like my age 38, 35 uh with stage 4 cancers.

It's really interesting and they aren't going to do that well. So what treatments can we do for cervical cancer? Well, what what what do I do? Surgery, yeah, so you're gonna take out the, we're gonna take out uterus, cervix, obviously tubes and ovaries because we're oncologists we like it all out. You in this we do radical hysterectomy, so that means not just uterus and cervix, we take the parametrium, so that's like if you imagine the uterus and cervix with the tubes, it's like the sheet over the uterus and cervix and. All that sheet and fluff either side that needs to go, OK? Because it can spread laterally into that and we also take the pelvic lymph nodes on either side around the common iliac sample the paraortics uh and the external iliac chain because that's where this spreads to. That is if it's surgically resectable again like I said to you, you don't want to be doing multimodality treatments if we think we can get it all out and get clear. Margins we do surgery. Anything more advanced like if we know we've got full nodal disease and clearly they're gonna need chemotherapy because it's like my chain of pearls, if it's in there, it's gone higher up, it's the small cancer cells we can't see, then we give primary chemo radiotherapy, OK? If we're gonna give chemo radiotherapy, we also do a PET scan, you know, positron emission tomography of whole body because you, you are much more. Likely to have small nets elsewhere that drastically alter your prognosis. Like my lady I said to you, she was 40, presented with all that. We thought they biopsied her all the tumour was all coming down the vagina, all in the side walls everywhere. She's got hydronephrosis. This is classic with cervical cancer because remember your ureters are really near with your bladder, so they usually present with uh hydronephrosis and advanced disease. It's so nasty. Young women and then she'd got a bony met in the skin as well on PET CT, that she was totally asymptomatic of. So when we know it's, it's gone rogue, it's quite advanced, you need to pet them because they might have chest, neck, head lesions, bone lesions.

If they present early, 95% survival, but it's, we see more and more in 3 and 4. OK. Just keep this in mind again, this isn't gonna be an exam question but you might just see it. Immunotherapy is now on the in our game, um, and we give PDL1 receptor antagonists, uh, called pembrolizumab and that is very good at controlling disease as well with chemo RD um. Alright, any questions on cervix? Yep. would, would there be a benefit to rolling out vaccinations to the wider? No. So they've looked at this, Maria. Well, kind of, they've looked, some trials have looked at vaccination of HPV following primary exposure, and there's no evidence it's beneficial. They've also looked at vaccinating people with things like SI 2 or 3 at that point, see if you can stop it progressing, and there's no benefit. Mara Kirigu's looking at that at Imperial, but it novel trial, but it's not, it's not done it. Fascinating. It's, yeah, this is, I like this. I like survival. Have you got a lecture at 10? When's your next one? Oh right, OK. Let me, um, cos it still says it's 9 o'clock. Let me just go through a variant and then I'll let you go. So two main types just quickly of cervix, squamous is 90% and then adenocarcinoma is less common. You don't need to know all this gear, but. You know, if you wanna look it up, if you wanna be a gyne oncologist, that is fantastic, join the crew, um. We would operate for probably up to a oh it's difficult really, so we'd do radicals onto a. 2B probably and then anything above that needs to be chemo rad cause you're not gonna clear it at all. You're not gonna clear that with surgery. And stage 4 clearly it's gone everywhere like bladder, bones, liver or lungs. Good survival pretty much mirrors endometrial, 95% at stage 1, 15% that poor lady, 5 year survival at 44. Miserable. OK, so lastly ovary, uh 72 year old comes, these are the really indolent ovarian cancer symptoms. Is why people present with what early or late stage disease in ovary. Late, yes, because how don't we all feel like this, like after you lot, after you've been on a bender, early satiety, bloating, abdominal pain, change in bowel habits. I never go on benders.