Pap smear: Why, when, how ?

Cancer Cancer Cervix. India. New Delhi Pap smear

Pap smear: Why, when, how ?

Pap smear: Why, when, how?

A few facts about female anatomy: The womb is also known as the uterus. It communicates with the vaginal canal; its opening into the vaginal canal is called cervix.

What is a Pap smear?

The name Pap is derived from the name of Dr.   George Papanicolaou, the originator of the Pap test. This is a simple painless test comprising two steps. The first step is collection of easily shed / scraped off cells from the opening of the womb i.e. the cervix, on a slide or in a bottle. The second step is examination of these cells under the microscope by a cytopathologist to detect abnormal cells.

What does an abnormal Pap smear indicate?

An abnormal Pap may indicate inflammation, infection, precancerous or cancerous change.

 

How does finding pre cancerous cells help?

Cancer of the cervix is India�s most common cancer as well as that of the developing world. It mainly occurs as a consequence of infection with the human papilloma virus. This infection results in transformation of  cells in the region of the cervix into abnormal dysplastic cells. Dysplastic cells left untreated, may transform into cancerous cells over a few years. However, if identified by a Pap smear and treated, conversion to cancer may be prevented. 

Why is a simple gynecological examination inadequate to do what a pap smear does?

Pap smears help in identifying abnormalities that are not visible  to the naked eye during examination. An abnormal pap smear in a lady with no obvious abnormal finding on examination, prompts the doctor to examine her under magnification using an instrument called colposcope. 

Who should undergo a Pap smear?

All women between the ages of 21 and 65-70 years, who are or have been sexually active, should undergo a Pap smear examination. 

How long does a Pap smear take? Is it painful?

Pap smears take around 5 minutes to perform. There is no pain; there may be some mild, transient, discomfort.

When should this test be performed?

The ideal time for women to undergo this test is 10 to 20 days after their period. Women who have undergone menopause may get the test done anytime.

It should be performed every 3 years. In case the test reveals an abnormality, a repeat test may be advised earlier than 3 years.

Why should a woman get a Pap test done?

The incidence of cervical cancer is very high in the developing world. The map above, courtesy the GLOBOCAN project,  illustrates the magnitude of the problem in South Asia, Africa and Latin America. A quarter of the world�s cancer cervix patients are Indian!

Pap smears can prevent this cancer, since precancerous abnormalities are amenable to outpatient gynecological procedures.

In patients in whom this disease has already occurred but is not causing symptoms, Pap smears may help detect the disease at an earlier stage.

In countries where Pap smears are performed regularly for screening, cervical cancer has become very infrequent.

 

Obesity & Cancer : Some Q & A.

Obesity & Cancer : Some Q & A.

Q: Medically speaking, how does one decide whether someone in obese?

A: While colloquially one refers to anyone with extra fat in their body as obese, medical speaking, an obese person in someone who has a Body Mass Index (BMI) of 30 or more , the BMI being calculated using the formula BMI = weight in kilograms / ( height in m X height in m).

Q: Is being obese the same as being over weight.

A: No, an overweight person is someone who�s BMI is equal to 25 or more, but is less than 30.

Q: Is the issue of obesity relevant to India?

A:  Studies have found that approximately 30 � 35 % of women in Delhi and Punjab are obese. Kerala and Goa follow closely.

 Q Is it true that obese persons are prone to certain cancers.

A4: Yes, obese persons are more prone to certain cancers, the risk also being dependent on gender and some other factors.

Q : Is obesity associated with an increased risk of breast cancer?

A  :Breast cancer is known to occur due to prolonged exposure to the female hormone estrogen. While the ovaries stop producing estrogen at menopause, fat cells continue to produce estrogen even after menopause. The higher levels of estrogen production in obese women predisposes them to developing breast cancer. This risk is highest in women aged 70 year and above. 

Q: Does obesity impact the chances of recovery from breast and other cancers?

A: A higher BMI results in poorer chances of recovery from breast cancer, cancer of the gall bladder as well as cancer of the uterus , kidney and food pipe, i.e. oesophagus.

Q  :Does being obese predispose women to any other cancers besides breast cancer?

A : Yes, obese women are more prone to developing cancer of the uterus. Besides this there are certain cancers, which occur more often in obese persons irrespective of gender.

Q : Which are these cancers that occur more often both in obese men as well as obese women?

A  : Cancer of the large intestine occurs more often in obese men and women but the risk is higher for men. This is likely to men being more likely to have fat deposits as the waist level, unlike women in whom the fat deposition may also be in the hips and thighs. This cancer has a stronger association with fat at the waist level.

Cancer of the lower end of the food pipe is also seen more often in obese persons likely due to reflux of acid from the stomach, leading to chronic irritation of the lower end of the oesophagus.

Gall stones occur more often in obese persons. These in turn predispose to cancer of the gall bladder.  Cancer of the pancreas also occurs more often in obese persons; this is thought to be due to higher levels of insulin in the body and its resultant ill effects

Obese men are also more likely to develop prostate cancer as compared to their slimmer counterparts.

Q : Does losing weight help?

A: Always. Not only does it reduce the risk of diabetes and heart ailments , losing weight also decreases the risk of breast cancer and prostate cancer. The impact of weight loss on other cancers is under study.

Chemo-radiotherapy help preserve normal physiological functions in rectal cancer patients.

Cancer India. New Delhi Radiotherapy Rectal cancer

Chemo-radiotherapy help preserve normal physiological functions in rectal cancer patients.

The terminal part of the large intestine is called the rectum. It functions as a receptacle for stool, and serves to hold and periodically, expel fecal matter through the anal canal. The anal canal, which is about 4 cm long, has a sphincter at the end, which ensures that stool is not expelled involuntarily. Stool is passed out of the body a combination of contraction of the intestinal / rectal wall to propel the stool forward and relaxation of the sphincter to allow the stool to be expelled from the body.

The rectum is  12 cm long and has a top, middle and lower third. Cancer may affect any part of the rectum and may be in the form of an ulcer, a growth or thickening. Patients suffering from rectal cancer may complain of fresh blood in the stool, pain while passing stool, constipation or change in bowel habits. Occasionally, rectal cancer may be detected when the patient is being investigated for anemia.

Patients in whom a rectal cancer is being suspected require a thorough clinical examination; a per rectal examination, in which the doctor will insert a gloved finger into the rectum, is mandatory. This examination helps the doctor to determine where the patient�s rectal growth starts in reference to the external opening of the anus. In addition, per rectal examination allows the doctor to judge whether the tumour is fixed to the deeper tissues or is superficial and confined to the wall of the rectum.

Following the examination, the patient requires to undergo an endoscopic examination called colonoscopy. This involves the insertion of a flexible tube inside the large intestine, to see it from within. Since patients with rectal cancer may have a second lesion elsewhere in the lumen of the large intestine, it is important that the entire length of the large intestine be visualized.

Any abnormality noted is then biopsied. The biopsy specimen is examined by a pathologist to determine whether the patient has cancer. Every growth / ulcer may not necessarily be cancerous.

On confirming cancer, the doctor will prescribe certain tests to determine the extent of disease i.e. the stage of disease. There are three aspects which are assessed, local spread of the tumour, number of lymph nodes involved and the presence of tumour in other organs, such as liver and lung. This is referred to respectively as T, N and M for Tumour, Node and Metastasis.

A surgical operation is necessary when attempting to cure rectal cancer.  The operation may be in the form of low anterior resection, in which the natural route for passage of stool remains intact, or in the form of abdomino-perineal resection ( APR), in which the natural passage is removed surgically, and a stoma i.e. opening, is fashioned on the belly. In the latter situation, stool is expelled into a bag. The latter operation is the only possibility in patients with presence of disease close to the opening of the anal canal or with infiltration of the muscle that imparts control over the passage of stool.

 Patients with disease that has spread beyond the wells of the rectum, or with evident spread to the lymph glands of the pelvis, or with the possibility of conversion of an abdomino-perineal resection to a surgery that does not require creation of a new passage are recommended concurrent chemo-radiotherapy before surgery.

Concurrent chemo-radiotherapy refers to the administration of chemotherapy along with radiotherapy. The aim of this chemotherapy is to enhance the effect of radiotherapy. This treatment has evolved as a result of a series of trials, in which addition of chemotherapy to radiotherapy was found beneficial. Patients may either receive the chemotherapy in the form of a prolonged intravenous infusion or in the oral form. The latter scores over the former, in view of convenience.

Radiotherapy is the treatment of cancer using ionizing radiation. X-rays are directed to the affected part of the body. The DNA of rapidly dividing cells is destroyed; most cancer cells divide very rapidly, and the damage to their DNA can kill these cells or limit their ability to divide and increase in number. Sophisticated techniques, 3DCRT, IMRT and IGRT, help limit the dose of  radiotherapy being received by normal structures in the vicinity of the rectum- the small intestine, the bone marrow on pelvic bones, the urinary bladder, the genitals.

Combined chemo-radiotherapy improves the possibility of undergoing surgery that helps preserve the normal passage of stools in patients thought fit only for APR. In addition, it also reduces the chance of cutting through the tumour during surgery.  The treatment lasts for 5 weeks; surgery is performed nearly two months after completion of chemo-radiotherapy, to maximize the chances of preserving the normal anatomy.