Cancer Cervix and Breast
Learning Resources:
Park’s Textbook of Preventive and Social Medicine
Public Health and Community Medicine (Shah, Ilyas, Ansari, Irfan’s)
Learning Outcomes:
The students should be able to:
1. Identify epidemiological determinants of common cancers
2. Suggest preventive measures for cancers in at-risk individuals and populations
3. Impart health education to prevent cancers.
Cancer Cervix
This is the second most common cancer among the women worldwide.
Natural History
Cancer cervix seems to follow a progressive course from epithelial dysplasia to carcinoma in situ to
invasive carcinoma.
Carcinoma in situ persists for a long time, more than 8 years on an average.
Pre invasive stage may take 15-20 years or longer to become invasive.
Once the invasive stage is reached, the disease spreads by direct extension into the lymph nodes and
pelvic organs.
Causative agent: There is evidence pointing to human Papilloma virus - sexually transmitted - as the cause of
cervical cancer. The virus is found in more than 95% of cancers.
Risk factors
Age: Cancer cervix affects relatively young women with incidence increasing rapidly from the age of 25-
45 years.
Genital warts: Past or present occurrence of genital warts are important risk factors.
Marital status: Cases are less likely to be single, more likely to be widowed, divorced or separated and
having multiple sexual partners. Cancer of cervix is very common in prostitutes.
Oral contraceptive pills: A recent WHO study finds an increased risk with increased duration of pill use
and with the use of oral contraceptives high in estrogens.
Socio-economic status: Cancer cervix is more common in lower socio economic groups reflecting poor
genital hygiene.
Early marriage: Early marriage, early coitus, early child bearing and repeated child birth have been
associated with increasing risk.
Prevention and control
Primary prevention: With improved personal hygiene and birth control, cancer of the cervix uteri will
show the same decline in developing countries as already experienced in most of Europe and North
America.
Secondary prevention
Early detection of cases (screening)
Treatment
Screening: The prolonged early phase of cancer in situ can be detected by the Pap smear. All women should
have a Pap test at the beginning of the sexual activity, and then every three years thereafter. A periodic pelvic
examination is also recommended.
Treatment: Treatment is radical surgery and radiotherapy.
The 5 year survival rate is virtually 100% for carcinoma in situ, 79% for local invasive disease and 45%
for regional invasive disease. Cancer cervix is difficult to cure once symptoms develop, and is fatal if left
untreated. Prognosis is strongly dependent upon the stage of disease at detection and treatment.
Breast cancer
Breast cancer is one of the commonest cause of death in many developed countries in middle aged women
and is becoming frequent in developing countries.
Risk Factors
Age: Breast cancer is uncommon below the age of 35, the incidence increasing rapidly between the ages
of 35 and 50, at the time of menopause there is decrease in incidence. A secondary rise in frequency often
occurs after the age of 65.
Family history: The risk is high in those with a positive family history of breast cancer, especially if a
mother or sister developed breast cancer when premenopausal.
Parity: An early first full term pregnancy seems to have a protective effect. Those whose first pregnancy
is delayed to their late thirties are at a higher risk than multiparous women. Unmarried and nulliparous
women tend to have more breast tumors.
Age at menarche and menopause: Early menarche and late menopause are established risk factors .The
risk is reduced for those with a surgically induced menopause.
Hormonal factors: Both elevated estrogens as well as progesterone are important factors in increasing
breast cancer risk.
Prior breast biopsy: Prior breast biopsy for benign breast disease is associated with an increased risk of
breast cancer.
Diet: Cancer of the breast is linked with a high fat diet and obesity.
Socio economic status: Breast cancer is common in higher socio-economic groups.
Miscellaneous: Increased risk of breast cancer has been observed in women exposed to radiation.
Prolonged use of oral contraceptive pills before the first pregnancy or before the age of 25 may increase
the risk in younger women.
Prevention
Primary prevention: The aim of primary prevention should be towards elimination of risk factors and
promotion of cancer education. The average age of menarche can be increased through a reduction in
childhood obesity, and an increase in strenuous physical activity.
Secondary prevention
Screening
Treatment
Screening
The basic techniques for early detection of breast cancer are
Breast self-examination
Palpation by a physician
Thermography
Mammography
All women should be encouraged to perform breast self-examination.
Palpation is unreliable for large fatty breasts.
Thermography has the advantage that the patient is not exposed to radiation. Unfortunately, it is not a
sensitive tool.
Mammography is the most sensitive and specific in detecting small tumors that are sometimes missed on
palpation. But it has some drawbacks like;
1. Exposure to radiation
2. Requires technical equipment of a high standard and experienced radiologists
3. Biopsy from a suspicious lesion may end up in a false-positive in as many as 5 – 10 cases for each case
of cancer detected.
4. Although mammography is superior over clinical examination in terms of sensitivity and specificity,
medical opinion is against routine mammography on the very young.
5. Women under 35 years of age should not have X-rays unless they are symptomatic or have a family
history of early onset of breast cancer.
Treatment
Treatment is by surgical removal, radiotherapy or chemotherapy. Some cases progress rapidly even if
diagnosed at an apparently early stage, others surviving for 20 years even after metastatic spread. In general
removal of tumor early is more likely to be curative than removal at a later stage.
