Cervical Cancer: Screening and Prevention

Cervical Cancer Screening and Prevention

• Cervical cancer mortality has declined due to widespread screening and prevention.
• Vaccination for high-risk HPV strains is a key prevention measure, as HPV is the leading cause of cervical cancer.

Cervical Cancer Screening Approaches

• There is a two-fold approach: HPV testing and screening for cellular changes via a Pap test.
• The Pap test (Papanicolaou test or Pap smear) screens for precancerous or cancerous lesions using a speculum and endocervical sampler.
• Cervical cancer screening options: cytology (Pap test), primary HPV testing, or co-testing (both).
• USPSTF recommends cytology every 3 years for women aged 21-29 with a cervix.
• For women aged 30-65, the recommendation includes cytology every 3 years, primary HPV testing every 5 years, or co-testing every 5 years.
• ACS supports screening low-risk women with a cervix starting at 25 years of age.
• From ages 25-65, primary HPV testing every 5 years is recommended, or co-testing every 5 years, or cytology every 3 years are acceptable options.
• This approach balances maximizing outcomes and minimizing unnecessary procedures, as HPV often resolves spontaneously in younger patients.
• Increased risk factors like immunosuppression, HIV, or DES exposure may require more frequent screening.

Early Cervical Cancer Symptoms and Management

• Early cervical cancer is often asymptomatic.
• Symptoms may include unusual discharge, AUB, or postcoital bleeding.
• Discharge may become dark and foul-smelling as the disease advances.
• Vaginal bleeding initially presents as spotting, becoming heavier and more frequent as the tumor grows.
• Late symptoms: pain, weight loss, anemia, and cachexia.
• Management follows ASCCP guidelines, which includes using online and mobile apps for guidance.
• Colposcopy is the primary diagnostic method, involving cervix examination with a magnification device after acetic acid application.
• Biopsies are done when abnormalities are seen.
• Treatment options: cryotherapy, LEEP, laser therapy, or cone biopsy to remove abnormal cells.
• Treatment depends on cancer stage and fertility concerns.
• Surgery or radiation therapy are main treatments for early cancer; advanced cancer may require surgery, chemotherapy, and radiation.

Ovarian Cancer Statistics and Risk Factors

• Ovarian cancer is the 5th leading cause of cancer death in women.
• Approximately 21,000 women are diagnosed each year in the US, with 14,000 deaths.
• Ovarian cancer often affects postmenopausal women
• Risk factors include personal/family cancer history, genetic predisposition, Lynch syndrome, endometriosis, nulliparity, and infertility.
• Factors reducing risk: childbirth, breastfeeding, or hormonal contraceptives for 5+ years.
• The reduced risk may be due to fewer ovulatory cycles.

Ovarian Cancer Types, Metastasis, and Symptoms

• Three major types: epithelial (90%), germ cell tumors (3%), and sex cord stromal (2%).
• Histologic grading is important for prognosis.
• Intraperitoneal dissemination is common, spreading to uterus, bladder, bowel, and omentum.
• In advanced stages, it can spread to stomach, colon, liver, and other body parts.
• Early ovarian cancer usually has no obvious symptoms; nonspecific symptoms may occur.
• Symptoms include pelvic/abdominal pain, bloating, urinary urgency/frequency, and difficulty eating or feeling full quickly.
• Later stages: abdominal enlargement with ascites, unexplained weight changes, nausea, and abnormal vaginal discharge/bleeding.
• Adnexal mass or lymphadenopathy may be present on physical exam or pelvic imaging.
• Early detection lacks accurate screening tests.
• For high-risk individuals, screening includes serum tumor marker CA-125 and pelvic ultrasound.
• CA-125 is positive in 80% of women with advanced ovarian cancer and is used to monitor disease progression and treatment response.
• CA-125 levels can be elevated in other cancers or benign gynecologic problems.

Ovarian Cancer Treatment and Management

• High-risk women may opt for prophylactic removal of ovaries/fallopian tubes and use OCPs.
• Salpingo-oophorectomy reduces ovarian cancer risk but does not eliminate peritoneal cancer risk.
• Initial treatment for all stages: TAH-BSO with removal of as much tumor as possible (tumor debulking).
• Other options: intraperitoneal and systemic chemotherapy, intraperitoneal radioisotope instillation, and external abdominal/pelvic radiation therapy.
• Combination chemotherapy and radiation therapy should be considered before single-modality treatments.
• Common chemotherapy agents are taxanes and platinums.
• Targeted therapies for advanced cancer: bevacizumab, rucaparib, and olaparib.
• Rucaparib and olaparib are PARP inhibitors, used for women with cancer associated with defective BRCA genes

BPH Overview

• Benign prostatic hyperplasia (BPH) is a condition where the prostate gland enlarges, disrupting urine outflow.
• Half of men show BPH signs by age 50, increasing to over 70% in men aged 60-69.

Etiology and Pathophysiology of BPH

• Hormonal changes during aging contribute to BPH development.
• Dihydroxytestosterone (DHT) stimulates prostate cell growth; excess DHT causes prostate tissue overgrowth.
• An increased estrogen-to-testosterone proportion may also contribute.
• Higher estrogen levels in prostate gland increase activity of substances, including DHT, that promote cell growth.
• BPH usually develops in the transition zone, compressing the urethra, leading to partial or complete obstruction.
• Compression of the urethra leads to clinical manifestations.
• There's no direct relationship between overall prostate size and the severity of manifestations or the degree of obstruction.
• Location of enlargement is most significant in the development of obstructive symptoms.
• Mild enlargement can cause severe symptoms, and extreme enlargement can cause few symptoms.

Risk Factors and Clinical Manifestations of BPH

• Risk factors: aging, obesity, lack of physical activity, high intake of red meat and animal fat, alcohol use, ED, smoking, diabetes, and family history.
• Manifestations develop gradually and may go unnoticed until prostate enlargement has been present for some time.
• Bladder compensation can mask early symptoms.
• As obstruction worsens, symptoms gradually worsen.
• Symptoms are categorized as irritative and obstructive.
• Irritative symptoms: nocturia, urinary frequency, urgency, dysuria, bladder pain, and incontinence.
• Nocturia is often the first symptom noticed.
• Obstructive symptoms: decreased force of urinary stream, difficulty starting a stream, intermittency, and dribbling.
• Both irritative and obstructive symptoms constitute lower urinary tract symptoms (LUTS).
• The AUA symptom index assesses voiding symptoms but is not diagnostic.
• Higher scores on the AUA-SI tool indicate greater symptom severity.

Complications, Diagnosis, and Treatment of BPH

• Complications: acute urinary retention, UTIs, bladder calculi (stones), and renal failure.
• Acute urinary retention causes sudden, painful inability to urinate, requiring catheter insertion.
• UTIs result from bacteria growth in residual urine.
• Severe infections can progress to pyelonephritis or sepsis.
• Bladder stones develop due to alkalinization of residual urine; their presence indicates obstruction.
• Renal failure can occur because of hydronephrosis due to urine flow obstruction.
• Diagnostic studies include a DRE to estimate prostate size, symmetry, and consistency.
• A urinalysis and urine culture can detect infection or inflammation.
• A PSA blood test screens for prostate cancer; patients with BPH may have slightly increased PSA levels.
• Serum creatinine levels can assess for renal insufficiency.
• Renal ultrasound may show hydronephrosis.
• A neurologic examination may be done, as similar symptoms occur with neurogenic bladder.

Advanced Diagnostic and Treatment Options for BPH

• In patients with abnormal DRE and high PSA, a transrectal ultrasound (TRUS) can be ordered as a stand-alone imaging test.
• TRUS-guided prostate biopsy is often performed, or a pelvic MRI focuses on the prostate.
• MRI-fusion targeted biopsy may be used if abnormal areas are seen on MRI.
• Assessment with MRI before biopsy and MRI-targeted biopsy are superior to standard TRUS biopsy in men at risk for prostate cancer.
• Uroflowmetry assesses urethral blockage
• Post void residual urine volume measures the degree of urine flow obstruction.
• Cystoscopy is done for unclear diagnoses or to evaluate prostatic enlargement.
• Urodynamic/pressure flow studies help assess bladder function and obstruction.
• Finasteride inhibits the type 2 isoenzyme and is suitable for moderate to severe AUA-SI scores.
• Symptom improvement may take 6 months and requires regular use.
• A common side effect is decreased libido due to blocked conversion of testosterone to DHT.
• TURP involves removing prostate tissue using a resectoscope inserted through the urethra and is the gold standard for surgical treatment.
• Marked symptom and urinary flow rate improvement is expected post TURP.

TURP Procedure and Potential Complications

• TURP involves no external incision where a resectoscope is inserted through the urethra to excise and cauterize obstructing tissue..
• A large 3-way indwelling catheter with a 30-mL balloon is inserted after the procedure to provide hemostasis and facilitate UD.
• Bladder irrigation (continuous or intermittent) manages hematuria and clots.
• TURP has a relatively low risk, assess for transurethral resection syndrome (TUR or TURP syndrome).
• TUR Syndrome include NV, confusion, bradycardia, and HTN.
• TUR syndrome is due to hyponatremia from long operative times and prolonged intraoperative bladder irrigation with iso-osmolar fluid.
• Risk dramatically decreases if the HCP uses saline irrigation during the procedure.
• Bleeding and clot retention can occurs after surgery.
• Patients taking aspirin, warfarin, or other anticoagulants must stop before surgery.
• BPH medications are stopped after the procedure.

BPH: Health Promotion and Acute Care

• Focuses on early detection and treatment.
• Further diagnostic screening may be needed when symptoms are present.
• Alcohol, caffeine, and other bladder irritants may worsen symptoms due to the diuretic effect.
• Compounds in cough and cold remedies, like pseudoephedrine and phenylephrine, worsen symptoms.
• These drugs are a-adrenergic agonists causing smooth muscle contraction and should be avoided.
• Urinating every 2 to 3 hours and when first feeling the urge will minimize urinary stasis and acute urinary retention.
• Patients should maintain normal fluid levels to avoid dehydration which increases the risk of infection.
• Antibiotics are usually given before any invasive genitourinary (GU) procedure and UTI must be restored/treated before surgery.
• Restoring urinary drainage and encouraging a high fluid intake (2 to 3 L/day unless contraindicated) are helpful in managing infection.
• A urethral foley catheter is needed to restore bladder drainage and 2% lidocaine gel is inserted into the UT.

BPH-Related Sexual Dysfunction and Post-Op Complications

• Patients may be concerned about the impact of the impending surgery on sexual function/performance.
• Ejaculate volume may decrease or be absent after the procedure resulting in retrograde ejaculation.
• Most types of prostatic surgery result in retrograde ejaculation which is not harmful.
• The main complications after surgery are bleeding, bladder spasms, urinary incontinence, and infection and plan of care is changed depending on those factors.

Post-op Care: Bladder Irrigation

• Typically done to remove clotted blood from the bladder and ensure drainage of urine.
• Bladder is irrigated either manually on an intermittent basis (50 mL) or more often, as continuous bladder irrigation (CBI) with sterile normal saline solution.
• Irrigating solution should be withdrawn with a syringe to remove clots that may be in the bladder and catheter.
• Painful bladder spasms often occur with manual irrigation.
• With CBI, the rate of infusion is based on the color of drainage and drainage should be light pink without clots.
• Continuously monitor the inflow and outflow of the irrigant; assess catheter patency.
• If the outflow is blocked and patency cannot be reestablished by manual irrigation, stop the CBI and notify the HCP.
• Blood clots are expected after prostate surgery for the first 24 to 36 hours, but large amounts of bright red blood in the urine indicate bleeding.
• Bleeding may occur from catheter displacement, dislodgment of a large clot, or increased abdominal pressure.

Post-operative Complications and Precautions

• Catheter displacement dislodges the balloon that provides counterpressure on the operative site.
• Traction on the catheter may be applied to provide counterpressure on the bleeding site in the prostate, thereby decreasing bleeding.
• Traction can result in local necrosis if pressure is applied for too long, pressure should be relieved on a scheduled basis.
• The patient should avoid activities that increase abdominal pressure these include include sitting or walking for prolonged periods and straining to have a bowel movement (Valsalva maneuver).
• Continuously monitor the inflow and outflow of the irrigant, assess catheter patency for kinks or plots, maintain a closed drainage system etc.
• Do not disconnect the system unless it is being removed, changed, or irrigated, discontinue CBI if obstruction occurs etc.

Prostate Cancer Overview, Etiology, and Pathology

• Prostate cancer is a tumor of the prostate gland and is the most common cancer among men, excluding skin cancer.
• 2nd leading cause of cancer death in men (exceeded by lung cancer).
• Slow-Growing and Androgen-Dependent cancer.
• More likely to develop in the peripheral zone (outer part of the prostate).
• Spreads by direct extension, through the lymph system, or through the bloodstream.
• The bloodstream spreads it to axial skeleton, liver, and lungs.
• Age, ethnicity, and family history are known risk factors.
• Diagnosis increases after age 50, median age at which to be diagnosed is 66.
• Many cases occur in younger men, sometimes with a more aggressive type of cancer.

Contributing Factors and Clinical Manifestations

• Diet factors and obesity may be related to prostate cancer.
• High intake of red/processed meat and high-fat dairy products increases risk.
• Low intake of vegetables and fruits may increase risk and environment may play a role (pesticides).
• Typically has no symptoms in early stages.
• Patients will have LUTS similar to those of BPH.
• Pain in the lumbosacral area that radiates down to the hips or the legs indicate metastasis.
• Tumor can can spread to pelvic lymph nodes, bones, bladder, lungs, and liver.
• Pain becomes the major problem when tumor has distanced.

Prostate Cancer Diagnostic Studies and Treatment

• Most men in the U.S. with PC are diagnosed with PSA screening
• Men should inform their HCP of potential risks and benefits for prostate cancer.
• Finasteride and dutasteride, can reduce the chance for getting diagnosed with PC.
• Early recognition and treatment are important to control tumor growth, prevent metastasis, and preserve quality of life.
• 5-year survival rate diagnosis at the local or regional is almost 100%.
• Grading systems: the Gleason score and the Grade Group which uses degrees from 3 to 5 based on the amount of glandular differentiation.
• Highest grade in 5 and can create an overall score ranges from 6-10.
• Lowest Risk Gleason score is Gleason 6 (3+3).
• A radical prostatectomy means the removal of prostate gland, seminal vesicles, and part of the bladder neck (ampulla).
• Removal of the entire P is done because cancer likes to occur in so many different places.
• A surgery is not an option for a late stage but surgery can relieve the symptoms.

Explore cervical cancer screening and prevention, highlighting the role of HPV vaccination and screening methods. Understand Pap tests, HPV testing, and cytology. Learn about USPSTF and ACS screening guidelines for women aged 21-65.