The cervix is the part of the uterus at its lower end and connects the uterus and the vagina. It opens up during childbirth to allow the delivery of the baby. It allows the passage of sperm into the uterus and fallopian tube and allows menses out of the uterus.

Cervical cancer is the second most common cancer among women. Worldwide 500, 000 women are diagnosed annually with a death rate of about 300, 000 women. In Nigeria, about 9, 000 women die yearly from the disease with about 14, 000 new cases diagnosed every year.

SYMPTOMS

Most cases of early-stage cervical cancer do not present with any symptoms. Cancer grows on the cervix and extends downwards from the cervix to the vagina, sideward to the surrounding structures such as the bladder, rectum, and kidney and upwards to the uterus. Most of the symptoms are due to increasing growth and spread to other organs.

Early symptoms due to growth on the cervix include bleeding after sex, bleeding in between menses, fresh bleeding after menopause and bleeding after a vaginal examination by a healthcare provider. As the cervix gets eroded and infected vaginal discharge which is offensive is noted.

As cancer spreads and metastasizes to the side of the vagina spread to the ureter which drains the bladder of urine results in difficulty passing urine or passage of bloody urine with damage to the kidney; spread to rectum causes constipation and over time weight loss.

Distant spread of cancer to:

• the bone can cause weakness of the legs and the bones to fracture without an accident [pathological fracture]
• the lung can cause chest pains, persistent cough, coughing up blood and difficulty breathing
• the liver can cause loss of appetite with nausea, swelling of the abdomen, extreme tiredness, yellowness of the eyes and itchy

CAUSES

Cervical cancer has been linked to infection with the Human Papillomavirus [HPV] which infects the basal cells of the cervix. HPV is the commonest sexually transmitted infection with about 80 – 90% of women getting infected with it during their lifetime. Women get infected with the virus during intimate sex; however, most cases of infection are neutralized by the body’s immune system within a few years. The persistence of HPV infection in some women over the years could lead to cervical cancer if undetected by routine screening.

Other factors that increase the risk of developing cervical cancer include having sex at an early age, smoking cigarettes, having multiple sexual partners, having many pregnancies, long term use of oral contraceptives, HIV positive women.

PREVENTION

Cervical cancer is a largely preventable condition. Primary prevention is achieved through HPV vaccination, while secondary prevention is achieved through screening.

HUMAN PAPILLOMAVIRUS VACCINATION

In the last decade, vaccines were developed which targeted about 70% of the cancer-causing strains of HPV. Vaccination with the vaccine before the initiation of sexual activity provides the best protection for the girl. The vaccines are also expected to protect against 75% of anal cancer, 62% of vaginal cancer, 45% of vulvar cancer and about 20% of oral cancers. These cancers are partly caused by some strains of HPV.

Ladies between the ages of 9 – 45 years are encouraged to take the vaccine.

DIAGNOSIS

1. PAP [PAPANICOLAOU] SMEAR

It is a cervical screening test where your doctor collects cells from your cervix [squamocolumnar junction] and smears it on a glass slide before applying a fixative and then sending it to the pathologist for review.

Routine Pap smear testing has reduced the incidence of cervical cancers significantly because women with precancer lesions can get treated on time.

1. HUMAN PAPILLOMAVIRUS [HPV] TESTING

HPV testing is now primary testing for infection. It checks for infection with cancer-causing strains of HPV. It is not commonly available in Nigeria for testing.

III.    VISUAL INSPECTION WITH ACETIC ACID [VIA] OR VISUAL INSPECTION WITH LUGOL’S IODINE [VILI]

In low resource settings without wide-scale availability of labs and pathologists to read results of Pap smear, Visual inspection with acetic acid or Lugol iodine are used. This involves staining the cervix with 5% acetic acid and visually observing it for precancer lesions.

The challenges of these tests are interobserver bias, their low sensitivity between 47 – 60%. This means they will only detect about one-half of persons with the lesion and the other half with the disease will be told they were okay.

1. COLPOSCOPY AND BIOPSY

Colposcopy and biopsy involve examining the cervix with a magnifying glass and taking a sample from an abnormal area for testing in the laboratory if a woman has an abnormal Pap smear and a positive HPV test.

TREATMENT

TREATMENT FOR PRECANCER STAGES

Abnormal cells on the cervix are termed CIN [Cervical Intraepithelial Neoplasia] and are usually removed or destroyed.

These treatments are as good as 95 % effective in curing precancer lesions and include:

• CONE BIOPSY: Removing an area that contains the precancer lesion
• LASER ABLATION: Uses laser technology to burn the area of the cervix with the abnormal cells.
• CRYOTHERAPY: Uses carbon dioxide or nitrous oxide to freeze and destroy the abnormal cells.
• LOOP ELECTRICAL EXCISION OF THE TRANSFORMATION ZONE: Involves using a hot knife to excise the diseased portion of the cervix

WHEN TO SEE A DOCTOR

If you have a daughter who is 9 years or older and has not taken her HPV vaccine, you can book an appointment with your doctor to discuss the HPV vaccine schedule.

• If you are above 25 years and sexually active, you should have a cervical smear every 3 years. You can book an appointment to see your doctor if you have not done a Pap smear recently.
• If you have any abnormal vaginal discharge/bleeding, you should make an appointment with your doctor.
• If you are past the age of menopause and start bleeding again, kindly see your doctor.

The ovaries are the female organ of reproduction that produces the egg [ovum]; and the female hormone, estrogen, and progesterone. Ovulation occurs in the ovaries every month and involves the monthly release of an egg.

Ovarian cancer is the 3^rd commonest gynaecological cancer in Nigeria. Worldwide 300, 000 new cases are diagnosed each year with about 185, 000 deaths. It constitutes about 5 -10 % of gynaecological malignancies in Nigeria. It is common in women from the fifth decade of life. However, young women are not immune to it.

SYMPTOMS

Ovarian cancer spreads through the blood, direct spread, through the lymphatic channel and the peritoneum. The spread of ovarian cancer goes undetected as the disease has no specific symptoms and most patients are diagnosed with late-stage disease.

These symptoms include:

• Abdominal swelling
• Feeling bloated
• Easy satiety
• Abdominal pains
• Irregular vaginal bleeding

CAUSES

The exact cause is unknown. It is known to be related to:

• Incessant ovulation: This may be due to the constant rupture of the ovary to release eggs and repair. If there is an abnormal repair, it could lead to cancer. Thus ladies who have not had babies are at increased risk while pregnancy and oral contraceptives reduce the risk.
• Family history: Women with a family history of ovarian cancer have an increased risk of developing it in the future. A history of breast cancer in the patient also increases the risk of ovarian cancer.

PREVENTION

Ovarian cancer has no defined precancer stage, so no screening method is currently approved for its prevention. CA 125 and transvaginal ultrasound scanning may be useful.

Its risk can be reduced by:

• Encouraging women to get pregnant.
• Taking oral contraceptive pills prevents regular ovulation.
• For women with a strong family history, removing the ovaries and fallopian tubes [salpingo-oophorectomy] is indicated. If a woman is found to have an alteration of the BRCA [Breast Cancer] gene she is at high risk of developing cancer. The BRCA gene suppresses cancers and restricts their growth.

DIAGNOSIS

If a patient is suspected to have ovarian cancer routine tests include:

• Blood Test: Full blood count, CA 125 [non-specific] which is normal in up to 45% of women with ovarian cancer.
• Radiological test: Abdominal Ultrasound Scan, CT scan of abdomen and pelvis, Chest X-ray to check for spread to the lungs.
• Staging and Diagnostic Laparotomy: This is used for the final diagnosis. Involves surgery to observe cancer, estimate the extent of spread and collect a specimen for testing.

TREATMENT

Surgery [Debulking Surgery]

This involves taking out as much of the cancerous structures as possible. It may involve removal of the ovaries and fallopian tube, uterus, omentum [fold of tissue connecting the stomach and other organs] and lymph nodes.

It allows chemotherapy given subsequently to be effective because the drugs can’t penetrate tumours more than 2 cm in diameter.

If a woman did not have debulking surgery before treatment or the debulking surgery wasn’t adequate, she could have an interval debulking surgery after some courses of chemotherapy.

Chemotherapy

Chemotherapy is the standard of care following debulking surgery.

Drugs used include Carboplatin, Paclitaxel, and Cisplatin.

Chemotherapy can be used in several forms:

• Neoadjuvant chemotherapy: Women who have advanced inoperable disease may have several cycles of chemotherapy before surgery is carried out. The drug reduces the bulk of cancer and makes it operable.
• Adjuvant chemotherapy: Drugs are administered after surgery [in addition to surgery]. This is the standard of care.
• Intraperitoneal chemotherapy: Involves administration of the drugs into the peritoneal cavity.
• Second-line chemotherapy: This is the use of other chemotherapeutic drugs in patients who were treated successfully but presented with a recurrence of the disease.
• Maintenance chemotherapy: This is done for persons who have achieved a cure to reduce the risk of relapse. It involves about 12 cycles of the medications.

WHEN TO SEE A DOCTOR

• If you have any of the above non-specific symptoms, you can book an appointment with your doctor to discuss the possible reason for your symptoms.
• If you have a relative who has or had ovarian, colorectal or breast cancer you should see a doctor and review your risk of ovarian cancer.

The breasts are two protrusions on the chest of both males and females. In the female, it secretes milk for the nourishment of the newborn. The female breast grows during puberty under the influence of estrogen and growth hormones.

Breast cancer develops in the breast tissue of women. It is the commonest cancer among women worldwide with over 2 million new cases every year and a yearly death rate of over 600, 000 women. This accounts for about 25% of cancers in women. Although breast cancer affects mainly women, about 1% of cases are seen in men.

Breast cancer occurs more in women 40 years and above; however, there is a rising incidence in younger women. 1 in 8 women will develop breast cancer in their lifetime.

In Nigeria, about 27, 000 women develop breast cancer yearly with over 14, 000 deaths.

SYMPTOMS

Breast Lump: this could be in the breast or the axillary lymph node [armpit]. It is usually the earliest sign for women who examine their breasts regularly or who go for regular clinical breast examination or a mammogram.

Other symptoms include:

Nipple discharge, which could be bloody

• Change in the contour of one or both breasts
• Skin dimpling
• Rash around the nipple area
• Breast pain

CAUSES

There is no known cause of breast cancer. However, some factors are known to increase their risk in women.

Family history: This contributes to about 10-15% of cases of breast cancers. Women whose mothers or sisters were diagnosed with breast cancer have an increased risk of developing the disease in the future.

Smoking: Cigarette smoke contains carcinogens that affect the breast. If you started smoking early and smoke many sticks of cigarettes daily, it increases your risk.

Sedentary lifestyle: An inactive lifestyle is linked to breast cancer possibly because of its link with obesity. This may contribute to 25% of breast cancer cases. Sitting regularly is associated with a higher death rate.

Alcohol: This is another risk factor for breast cancer. The greater the number of drinks consumed the higher the risk of developing the disease. Alcohol could impair the ability of the liver to clear substances that cause cancer.

Hormonal contraceptive: There is a link between it and breast cancer. This may be related to the number of years of use.

PREVENTION

Breast cancer risk can be reduced by the following:

Regular breast examinations are among the best ways to reduce the risk of breast cancers. Different ways of examining the breast include:

1. Self-breast examination

This is a screening method used in an attempt to detect breast lumps or any abnormal findings on the breast. It should commence from the age of 18 – 20. It is best done just after the menses. For women who no longer menstruate, you can choose a particular day of the month and perform the examination regularly.

2. Clinical Breast Examination

This involves medical personnel examining your breasts.

3. Mammogram

This uses X-rays to screen the breast for any masses. The breast is usually squeezed between the machines while the radiographer takes images of the breast for interpretation by the radiologist. Women are counselled to perform mammograms every 2 to 3 years from age 40 to 70 years.

Other ways to reduce your risk of breast cancer include:

• Ensuring you maintain a healthy weight and live an active life
• Breastfeeding babies has been known to reduce its incidence
• Breast removal surgery for those at high risk

DIAGNOSIS

If a woman is suspected to have breast cancer, the health care provider may want to carry out the following tests to make a diagnosis.

1. Breast examination may pick up a lump.
2. II. A mammogram/breast ultrasound will be useful in increasing the suspicion of the doctor.

III. Fine needle aspiration cytology [FNAC] which involves inserting a needle into the suspicious site and collecting fluid for examination under the microscope may be carried out.

1. IV. Incisional biopsy which involves taking a portion of the breast mass out through surgery for histology may be done.
2. V. Excisional biopsy which involves removing the whole breast mass for examination in the laboratory may be performed depending on the preference of the doctor.

TREATMENT

Surgery: Surgery is done to reduce the bulk of cancer by removal of the breast and surrounding structure to which there is a possible spread.

A lumpectomy could be done to remove just the lump or a mastectomy to remove the whole breast.

This is the primary way of treating most breast cancers.

Chemotherapy: This involves drugs used in addition to surgery to reduce the risk of recurrence of cancer or slow its progress. Drugs used include cyclophosphamide, doxorubicin, methotrexate, and fluorouracil. These drugs are used as a combination regimen. Other drugs used include hormone-blocking drugs using Tamoxifen or Letrozole.

Monoclonal antibodies such as Trastuzumab are used for HER2 Positive cancers to improve survival.

Radiotherapy: This uses ionizing radiation to kill cancer cells on the breast and reduce the risk of recurrence. It could kill microscopic cancer cells that were not found during surgery. It is usually given after surgery.

WHEN TO SEE A DOCTOR

• If you have never had a breast examination and your above 21 years, you can book an appointment with your doctor to discuss your risk and request a breast examination.
• If you have any of the above symptoms see your doctor urgently.
• If you have a mother or sister who has breast cancer or died from it you should book an appointment with your doctor.
• If you are above 40 years and not done a mammogram yet you should make an appointment with your doctor.

The endometrium is the inner lining of the uterus that gets shed off during the monthly menses. It prevents the walls of the womb from fusing.

Endometrial cancer affects this lining of the uterus [womb], unlike cervical cancer that affects the cervix [neck of the womb]. It is one of the most common cancers in developed countries. In Nigeria, it is not as common as possible because of our life expectancy. It occurs more in women in their 60s although some women develop it earlier.

SYMPTOMS

Most women will present with postmenopausal bleeding. This is the resumption of fresh bleeding after they have stopped bleeding for up to one year.

For other women, frequent heavy menses or bleeding in between your period should make you visit your gynaecologist.

Some women will present with pelvic pain.

CAUSES

There is no known cause for endometrial cancer; however, several factors have been identified in clients with the disease

1. Family history: Women with a family member diagnosed with endometrial cancer have an increased risk of developing the disease themselves. Some of these families also have a risk of developing colon cancer.
2. ii. Overweight women: This may be because excess body fat gets converted to estrogen which acts on the endometrium.

iii. Childlessness: Infertility or volunteering not to have children increases the risk of endometrial cancer by increasing the number of menstrual cycles.

1. Anovulation: This occurs when women do not ovulate. This occurs in conditions such as Polycystic Ovarian Syndrome [PCOS].
2. Age: The risk of endometrial cancer rises with age.
3. Diet high in fat: These diets have a large calorie dose that leads to obesity which is a risk factor.

vii. History of endometrial hyperplasia: Endometrial hyperplasia is a condition in which there is increased growth of the endometrium possibly from irregular menstruation. It poses a risk if not treated.

viii. Use of HRT [Hormone Replacement Therapy]: Its use to treat menopausal symptoms with estrogen alone increases the risk.

PREVENTION

Although most cases of endometrial cancers may not be preventable, the following could help reduce your risk of developing endometrial cancer.

• Weight reduction and an active lifestyle
• Use of combined oral contraceptive pills for at least 1 year
• Having children
• Getting treated for abnormal vaginal bleeding
• If you have to use hormone replacement therapy for menopausal symptoms, ensure your doctor adds a progestin to counteract the effect of estrogen.

DIAGNOSIS

Investigations needed for diagnosis include radiological tests and biopsy.

Transvaginal Ultrasound Scan

Your doctor uses a transvaginal scan to check the thickness of the endometrium. If the thickness is much larger than normal for the age of the woman and phase of her menstrual period further tests are carried out.

Sonohysterogram

This involves inserting fluid into the uterus and then carrying out a transvaginal scan. This procedure helps distend the uterus and makes problems within the uterus easy to see.

Endometrial Biopsy

This involves taking a specimen from the lining of the womb and sending it to the laboratory for evaluation. It is a blind procedure and areas with challenges can be missed.

Hysteroscopically directed biopsy

This method involves using a camera and light source to look into the uterus. It is more accurate and areas that look diseased can be biopsied.

TREATMENT

Surgery

This involves total abdominal hysterectomy [removal of the uterus and cervix], bilateral salpingo-oophorectomy [removal of the ovaries and fallopian tubes], peritoneal cytology and pelvic and para-aortic lymphadenectomy. This way most of the cancer cells and areas it has spread to are reduced.

Chemotherapy

Cisplatin is the major medication for cancer treatment. It discourages the growth and spread of cancer cells.

WHEN TO SEE A DOCTOR

• If you are postmenopausal [you have stopped menstruating and notice you start bleeding again]
• If you are still menstruating and notice a change in your menstrual pattern such as heavier flow, bleeding in between menses for more than 1 cycle