Transcript Obgyn Week 4b - CatsTCMNotes

Obgyn Week 4b
Cervical Dz, Gynecologic Cancers
Cancer
• Most common cancers in U.S. women
By occurrence
Breast
By mortality
Lung
Lung
Colorectal
Endometrial
Breast
Colorectal
Ovarian
Non-Hodgkin
lymphoma
Pancreatic
Cancer
• Most common cancers in U.S. men
By occurrence
Prostate
By mortality
Lung
Lung
Colorectal
Bladder
Prostate
Colorectal
Pancreatic
Melanoma
Leukemia
Cancer
• General Cancer terms:
– Stage: determined by clinician; is the
degree of invasion of the tumor; usually on
a scale of 1-4
– TNM staging where n=nodes, m=mets
– Grade: determined by pathologist; is the
degree of resemblance of the tumor to its
surrounding tissue
• The higher the grade the less differentiated
Cancer
• More general cancer terms:
– Carcinoma: tumor derived from epithelial
cells
– Sarcoma: derived from connective tissue
– Adeno-: prefix to denote glandular
involvement
– Lymphoma: derived from hematopoietic
cells (blood cancer)
Cancer
• TCM description of process
(from Dr. Fritz)
– Deficiency state (improper diet/lifestyle/emotion)
– External pathogen invasion creates disharmony
– Blood stastis/phlegm accumulation --> tumor
formation
– Perpetuation of internal cold-heat cycle
– Body unable to disperse, tumor grows
PAP
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Part of the yearly well-woman exam
PAP smear (named after Dr. Papanicolau)
Is a screening tool only
Looks for abnormalities in cervical cells
Is susceptible to false + and false - results
– False negative rate about 5-20%
– False positive due to Trichomonas or HSV
infections or if history of chemotherapy
PAP
• Screening guidelines:
– Beginning at age 18 or upon sexual activity
– ACOG (American College of Gynecology)
recommends annual screening indefinitely
– American Cancer Society recommends
screening at least every 3 years (if no
abnormal results); more frequent if patient
is at increased risk
– Both recommend pelvic exam annually for
all women over 40 years old
PAP
Cervical Dysplasia
• Precursor to cervical cancer
• Aka Cervical intraepithelial neoplasia
• Dysplasia = abnormal tissue
development; refers to pre-cancerous
changes in cervical cells
*Cervical cancer of squamous cells is a
preventable disease
Cervical Dysplasia
• Risk factors:
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Early age 1st intercourse; 2x risk if age 14 or 15
More than 3 sexual partners
Giving birth before age 22
Cigarette smoking (2x risk)
Low socioeconomic status
OCP use esp. if for 5-10 years (barrier methods
protective)
– Alterations in immune status (HIV, Lupus)
– Current or past chlamydia infection
– Vitamin A, C, and folate deficiency
Cervical Dysplasia
• Pathology:
– Cervix covered with mucus membrane
– During adolescence, columnar epithelium
changes to squamous epithelium
– Squamo-columnar junction is most
susceptible to dysplastic changes
– Junction surrounds cervical os; recedes
into os around menopause
Cervical Dysplasia
Cervical Dysplasia
• Mild dysplasia: basal layer thickens to about
the bottom 1/3rd of membrane
• Moderate: basal cells thicken to middle 3rd
• Severe: basal cells thicken to more than
2/3rd of membrane
• Carcinoma in situ: basal cells through entire
thickness of membrane
Cervical Dysplasia
Cervical Dysplasia
Cervical Dysplasia
• Classification systems (PAP smear)
– Bethesda Classification:
• Low-grade SIL squamous intraepithelial lesion
– Evidence of HPV
– Mild dysplasia
• High-grade SIL squamous intrapeithelial lesion
– Moderate to severe dysplasia
– Carcinoma in-situ
Cervical Dysplasia
• Traditional Classification
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CIN I: mild dysplasia
CIN II: moderate dysplasia
CIN III: severe dysplasia
Normal
Metaplasia
Inflammation
Atypia - cells are not dysplastic but not ideal - show
evidence of repair (from infection, inflammation, etc)
ASCUS: atypical squamous cells of undetermined significance
AGCUS: atypical glandular cells of undetermined significance
Cervical Dysplasia
• Etiology
– HPV: Human Papilloma virus
• Most evidence of causal relationship
• Subtypes 16 and 18 most aggressive: 18
months until cancer development
– HSV II: Herpes simplex virus
• Virus detected in cervical cancer tissue
• Antibodies found in blood of women with
cervical dysplasia and cancer
• No clear cause-effect determined (yet)
Cervical Dysplasia
• Approximately 70% women have HPV
infection at some point in their lives
• Most infections and subsequent dysplasia
regress on their own
• ~10% cervical cancer cases appear to
rise in absence of detectable HPV DNA
Cervical Dysplasia
• Evaluation:
– Colposcopy: magnification of cervical
transformation zone (squamo-columnar junction)
– Biopsies of tissue w abnormal appearance
– Large abnormal transformation zone correlates
with high-grade lesions
– Small abnormal transformation zone correlates
with low-grade lesions
– If entire transformation zone not visualized, need
LEEP or conization procedures to sample
endocervical canal
Cervical Dysplasia
• Various levels of dysplasia will have
different treatment plans
Low-grade - often can recheck in 3-6 months
High-grade- colposcopy to determine extent
• Cone biopsy if indicated
• Re-PAP more frequently if indicated
Cervical Dysplasia
• Conventional Management:
Cryotherapy: frozen carbon dioxide or nitrous oxide
applied to abnormal tissue via a probe
– Purpose is to eradicate abnormal epithelium a few
millimeters thick
– No anesthesia required
– May result in cervical stenosis
– Cure rate 91% CIN I-II; 78% CIN III
– Follow up in 4 months to visualize tissue
Laser therapy:
– Vaporizes target tissue
– Equipment more expensive and requires
specialized training
Cervical Dysplasia
• Naturopathic Management
– Nutrition and supplementation
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Focus on colorful veggies and fruits, cruciferous veggies
Folate 10 mg/day
Vitamin E 400-800 IU/day
Green tea capsules
DIM or I3C - both
– Vaginal suppositories
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Vitamin A nightly for 6 nights
Green tea nightly for 6 nights
(alternate weeks for 4-12 weeks)
Escharotic treatments also available - weekly, in office
– Current research suggests cervical dysplasia may
be evidence of FOLATE deficiency
Cervical Dysplasia
• HPV vaccine: Gardasil
– Approved by FDA June 2006
– Protects against 4 HPV strains (out of
possibly hundreds): HPV 6, 11, 16, 18
– Vaccine studied for 4 years before release
– Already on vaccine schedule for children
– Marketed to girls as young as 11 years old
– Research underway to study vaccine on boys
Cervical Dysplasia
• Reported Gardasil adverse effects:
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Collapsing after vaccine
Dizzy spells
Fainting
Seizures
Death
• Vaccine recipients may still contract
HPV and develop cervical dysplasia
• Lifestyle choices, screening, and
prevention are key against cervical ca.
Cervical Cancer
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Third most common gynecologic malignancy
Eighth most common malignancy in US women
4,600 deaths annually
Mean age 50 but may occur as young as age 20
HPV types 16, 18, 31, 33, 35, 39 increase risk
Cancer occurs when cervical dysplasia or
carcinoma in situ penetrates the basement
membrane and invades surrounding tissue
Cervical Cancer
Cervical Cancer
• Most (80-85%) cervical cancer is
squamous cell carcinoma
• The rest is mainly adenocarcinoma
– No clear relationship to HPV etiology
• Rare:
– sarcoma, small cell neuroendocrine tumors,
clear cell adenocarcinoma
Cervical Cancer
• Spread:
– Via direct extension to surrounding tissues
– Via lymph to pelvic and para-aortic lymph
nodes
– Via lymph to extra-abdominal lymph nodes
: left scalene and left supraclavicular nodes
– Via blood to distant tissues - possible but
rare in cervical cancer (Lung, liver, bone)
Cervical Cancer
• Main symptoms:
– CIN: usually asymptomatic and discovered with
PAP smear
– 50% women with cancer have never had a PAP
or haven’t had one in over 10 years
– Early stage: irregular vaginal bleeding
(postcoital, intermenstrual, menometrhorrhagia)
– Advanced: foul-smelling discharge, abnormal
bleeding, pelvic pain
– Late-stage: obstructive uropathy, back pain, leg
swelling
Cervical Cancer
Staging is most important determinant of prognosis
• Stage 0 - full-thickness involvement of the
epithelium without invasion into the stroma
(carcinoma in situ)
• Stage I - limited to the cervix
• Stage II - invades beyond cervix
• Stage III - extends to pelvic wall or lower third
of the vagina
• Stage IV - metastasis
Cervical Cancer
Cervical Cancer
• 5-year survival rates by stage:
– I: 80-90% (invasive squamous cell
carcinoma remains localized for a long time)
– II: 50-65%
– III: 25-35%
– IV: 0-15%
• ~80% recurrences manifest within 2 years
– Recurrences may happen as long as 15
years after primary therapy
Cervical Cancer
• Diagnosis:
– Pelvic exam/ biopsy
– CT scan: best method to determine lymph
node involvement
• Fine-needle aspiration of suspicious nodes
– IV pyelogram: determine urinary system
involement
– Chest x-ray
– Barium enema/ sigmoidoscopy
Cervical Cancer
• Treatment
– Stage IA1/ limited tumor spread:
hysterectomy
– Stage IA2, IB where cancer has spread
over 3 mm past basement membrane:
• Radical hysterectomy (uterus, cervix, ovaries,
oviducts)
• Bilateral lymph node dissection
• Removal of adjacent ligaments (round, broad)
Cervical Cancer
• Treatment
– Stage IIB, III, IV: Radiation primary
treatment
• Sometimes with chemo as a radiation sensitizer
– If metastases beyond regional lymph nodes
or if recurrent nonresectable disease:
systemic chemotherapy
• Not curative
• Tumor regression occurs in only 25-30% women
and is short-lived
Endometrial Cancer
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Most common gynecologic malignancy
Fourth most common cancer in women
Affects mainly postmenopausal women
Peak incidence 50-60 year old women
Less than 5% are under 40 years old
Accounts for approximately 6500 deaths
yearly in US; 36,100 new cases in US/ year
Endometrial Cancer
• Higher incidence in women with:
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Increased dietary fat intake
Obesity ( 3x if 21-50#; 10x if >50# overweight)
Pelvic radiation therapy
Family/ personal history of breast, ovarian ca.
Diabetes (2.8x); Hypertension, PCOS
Increased exposure to estrogen: unopposed
estrogen therapy, nulliparity.
– Late menopause (>52yo), annovulation,
estrogen-secreting tumors
Endometrial Cancer
• Spreads:
• Via surface of uterine cavity to cervical canal
• Through myometrium to serosa to peritoneal
cavity
• Via Fallopian tube to ovary
• Via blood to distant sites
• Via lymph to lymph nodes
Endometrial Cancer
• Precursor is endometrial hyperplasia (occurs
during periods of unopposed estrogen)
• The higher the grade, the greater the chance
of deeper invasion of myometrium or extrauterine spread
• Over 80% of endometrial cancer is
adenocarcinoma
• Sarcomas approx 5%
Endometrial Cancer
• Symptoms
– Vaginal discharge
– Abnormal bleeding patterns
• 1/3 of post-menopausal bleeding is
due to endometrial carcinoma
Endometrial Cancer staging
• Stage IA: tumor limited to the endometrium
• Stage IB: invasion of less than half the
myometrium
• Stage IC: invasion of more than half the
myometrium
• Stage IIA: endocervical glandular
involvement only
• Stage IIB: cervical stromal invasion
Endometrial Cancer staging
• Stage IIIA: tumor invades serosa or
adnexa, or malignant peritoneal cytology
• Stage IIIB: vaginal metastasis
• Stage IIIC: metastasis to pelvic or paraaortic lymph nodes
• Stage IVA: invasion of the bladder or
bowel
• Stage IVB: distant metastasis, including
intraabdominal or inguinal lymph nodes
Endometrial Cancer
Endometrial Cancer
Endometrial Cancer
• Diagnosis
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Endometrial biopsy or Fractional D&C
Transvaginal ultrasound
CT if metastases suspected
Stool guaiac test if bowel metastases
suspected
Endometrial Cancer
• Treatment
– Stage I: surgery
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Hysterectomy
Bilateral salpingo-oopeherectomy
Peritoneal cytologic examination
50-70% cases no need for post-op radiation
If patient unable to tolerate surgery, radiation
alone used
Endometrial Cancer
• Treatment
– Stages II, III
• Additional surgery: para-aortic
lymphadenectomy
• If extra-pelvic cancer: add radiation,
chemotherapy, and/ or hormone therapy
– Hormone therapy includes progestin therapy to induce
regression of tumors, occurs in 35-40% of patients
– Stage IV: systemic chemotherapy
Endometrial Cancer
• Most recurrences of adenocarcinoma of
endometrium occur within 3 years of dx
• 90% occur within 5 years
• ERT controversial after treatment for
endometrial cancer; do benefits
outweigh risk?
Other gynecologic cancers
• Vulvar cancer
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3-4 % of gynecologic malignancies
Average age at diagnosis is 70
90% squamous cell carcinoma
Risk factors:
• Chronic vulvar pruritis
• Vulvar dystrophy
• Vulvar intraepithelial neoplasia (premalignant)
Other gynecologic cancers
• Vulvar cancer
– Symptoms: palpable lesion during routine
PE; may have vaginal discharge/ bleeding
if lesion necrotic or ulcerated
– 20% asymptomatic
– Diagnosis: punch biopsy
– Differentials: STI, basal cell carcinoma,
condyloma acuminatum, melanoma,
Paget’s disease
– Treatment: surgery (vulvectomy), lymph
node dissection
Other gynecologic cancers
• Vaginal cancer:
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1% gynecologic cancers
Average age diagnosis: 60
95% cases are squamous cell carcinoma
Risk factors:
• HPV infection
• Cervical/ vulvar cancers
Other gynecologic cancers
• Vaginal cancer
– Symptoms: abnormal bleeding patterns,
vaginal discharge
– Diagnosis: punch biopsy, wide local
excision if larger lesion
– Treatment: surgery (vaginectomy), radiation
Other gynecologic cancers
• Fallopian tube cancer
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Rare
Average age 50-60
Risk factors not well defined
Symptoms: chronic salpingitis, general
inflammation, vague abdominal pain,
bloating
– Remote history of infertility
– Treatment: surgical
Cancer…
A few things to think about
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In the office you may discover a problem or
symptom pointing to possible malignancy such
that immediate oncology workup is desirable.
How do you word that to your patient without
frightening them?
What if the patient has already been diagnosed
with a malignancy recently, but doesn’t
understand the situation or the threat. You have
to figure out why they did they not understand.
Was it just the shock? Were they not told? What
do you say? Suppose they are in denial. How do
you tell? How forcefully do you explain? What is
your duty here?
Questions to Consider
• What do you say when asked, “Can you really
help me?”
• What do you say when asked if they should do
chemotherapy or radiation?
• What do you say when they have searched and
found some completely off-the-wall treatment?
• When do you explain what you can deliver?
• What can you deliver?
Talking to Patients with Cancer
• There is absolutely nothing routine about conversing
with someone who has cancer, whether it is the first
visit or the tenth. There is a certain edginess to the
meeting for both the clinician and the patient. Neither
of you knows what to expect. Get past that quickly.
• If the diagnosis of cancer is recent, it is easy to start by
saying, “That must have been a great shock”. This
opens the floor for the patient to start talking.
• The patient has an enormous amount of information for
you to acquire about their situation. So along with
using your left brain to keep them comfortable, your
right brain is getting all the pertinent facts.
• Clarify early on: What are they looking for from you?
Naturopathic Cancer Care
• Cancer Situation 1 – patient has elected
standard oncology care (our role is adjunctive
supportive care avoiding interference)
• Cancer Situation 2 – after remission from
standard oncology care (repair & prevention)
• Cancer Situation 3 – after standard oncology
care without hope of remission (repair & aim
for life extension)
• Cancer Situation 4 – the patient who declines
standard oncology care (aim for life extension)
Basic Cancer Tx Info
• 98% of the chemistry in cancer cells is
identical to that of normal cells
• Any treatment that affects cancer cells
will disturb normal cells as well
• Most cancer cells are more susceptible
to therapies, and the normal, healthy
cells are more resilient,
• But there will be side effects.
Common SEs of Cancer Tx
(and natural support for them)
• Chemotherapy
– Oral mucositis (oral glutamine swish and swallow feeds epithelial cells - start preventatively)
– Fatigue and Brain fog (acetyl-L-carnitine crosses
BBB, protects brain from toxins)
– Neurotoxicity/peripheral neuropathy (vitamins E and
B-12 help protect nerves)
– Depression (acetyl -L-carnitine 1000mg bid)
– Cardiotoxicity (CoQ10)
– Cachexia (coconut milk/oil, bone broths)
– Nausea (ginger, mint, B vitamins)
(Antioxidant therapy stopped during chemo, but given before and after)
Common SEs
(and natural support) con’t
• Radiation burns:
– Vitamin E 400 IU bid (several days before,
during, and after tx) reduces burning
– Fish oil concurrent with radiation
– Caffeine on days of treatment
– Aloe vera topically
Natural Cancer Tx - MCP
• Modified citrus pectin (MCP) - research has
shown it to help prevent metastases and
decreases tumor growth.
• Pectin - is a carbohydrate material occurring
naturally in food. It provides needed soluble
fiber, but is poorly absorbed. When the
molecular size of pectin is decreased, it is
absorbed. It can bind to the surface of tumor
cells and produce the results mentioned above.
MCP
• Several products claim to be MCP. Most have
little benefit. Only two are researched to any
extent. These are “PectaSol” (by EcoNugenics)
and “Fractionated Pectin” (by Thorne Research).
• (Grocery stores may have a pectin product
labeled "MCP", which does not stand for Modified
Citrus Pectin and is not the same thing.)
• MCP is available in capsules or powder. Powder
is best financially, and may disperse better.
• Suggested dosage is one rounded teaspoonful (5
grams) three times daily. Place the rounded
teaspoon dose in a few ounces of warm water
and stir/shake until suspended and drink.
Natural Cancer treatment
• Anti-cancer herbs
• Many mushroom species
• Which other Chinese herbs?
• Many Western anti-cancer herbs are also toxic,
must be used cautiously and judiciously
Natural Cancer Treatment
• Shen management (from Dr. Fritz)
– Counseling
– Support from community, family, other
cancer survivors/ patients
– Mind-body techniques: meditation, qi gong,
tai chi, yoga
– Energy work: reiki, acupuncture (Kaiser
Permenente recommends their oncology
patients seek acupuncture)
A word on nutrition and health:
1.
The Japanese eat very little fat and suffer fewer
heart attacks than Americans.
2. The Mexicans eat a lot of fat and suffer fewer heart
attacks than Americans.
3. The Chinese drink very little red wine and suffer
fewer heart attacks than Americans.
4. The Italians drink a lot of red wine and suffer fewer
heart attacks than Americans.
5. The Germans drink a lot of beers and eat lots of
sausages and fats and suffer fewer heart attacks
than Americans.
CONCLUSION: Eat and drink whatever you
like. Speaking English is apparently what kills you.