Prevention of Genital Tract Malignancies: A Task for all.

Abstract

As more is learned about the factors associated with malignant diseases of the female genital tract comprising of cancers of the vulva, vagina, cervix,
endometrium, fallopian tubes and ovaries, there is hope of preventing certain types.
This involves elimination or control of what are believed to be causal agents, a typical example being the human papilloma virus (HPV) which is the prime aetiological factor of
cervical cancer.
Screening modalities in the developed world constituted a great step in the
prevention of cervical cancer by over 80%.
The advent of cervical cancer vaccination revolutionized the prevention of cancer of the cervix. However, there is scarcity of cervical cancer vaccines in the
developing countries of the world. Where these vaccines are available the cost is a challenge because majority of the masses cannot afford them.
Vulvectomy for dysplasia of the vulva epithelium has its place but does not always prevent squamous cell carcinoma in that site.
Hysterectomy for all women showing cervical epithelial dysplasia or
suffering from post menopausal bleeding or discharge or whose family is completed could well reduce the number of cancer if it is cervical cancer or cancer of
the corpus uteri. Such an approach, however, is likely to involve operative mordalities.
Reason and safety impose strict limit on the place of prophylactic surgery in the prevention of cancer of the vulva, cervix, corpus uteri, fallopian tubes and ovaries.

Early Diagnosis
It is generally accepted that an early cancer is
more amenable to cure than one which has been
present for sometimes.
11 It is important to pay heed to
the first suspicious symptoms or signs presented by
the patient, for example, irregular uterine bleeding or
discharge occurring after the age of forty years.
12
Although early diagnosis and treatment must offer the
patient a better chance of survival, they do not always
make much difference that might be expected.1,12

Stage 1 cases of cancer of the cervix can do badly
while more advanced ones sometimes respond well to
treatment.
13 This is because certain cancer cell growth
divide the vascular channel at a very early stage,
whereas others can come to terms with their cancer
cells,14 even to the extent of inactivating the malignant
cells liberated into the blood or lodged in the bone
marrow.
15 The first type is rarely cured no matter how
early the occurrence, whereas the second is nearly
always cured no matter how long treatment is
deferred. 14
The result of therapy according to the stage of
cancer of the cervix clearly shows that the less the
clinical extent of the disease the better the outlook.12-14
However, it is often assumed that the extent of a
cancer represents its age.13

Full text

Greener Journal of Medical Sciences, vol. 10, no. 1, pp. 12-14, 2020
Greener Journal of Medical Sciences
Vol. 10(1), pp. 12-14, 2020
ISSN: 2276-7797
Copyright ©2020, the copyright of this article is retained by the author(s)
https://gjournals.org/GJMS
Prevention of Genital Tract Malignancies: A
Task for all
Kalio DGB1; Eli S2; Briggs NCT3; Iwo-Amah R1; Okagua KE1
Department of Obstetrics and Gynaecolology, Rivers State University Teaching Hospital.1
Mother and Baby Care Global Foundation.2
Rivers State Hospital Management Board.3
ARTICLE INFO.
Article No.: 042520063
Type: Commentary
Accepted: 30/04/2020
Published: 09/05/2020
*Corresponding Author
Dr. Eli S, MB BS, FWACS, FIMC, CMC
E-mail: elisukarime@ gmail. com
Keywords: prevention;
genital tract; malignancy; task
LETTER TO THE EDITOR
As more is learned about the factors associated
with malignant diseases of the female genital tract
comprising of cancers of the vulva, vagina, cervix,
endometrium, fallopian tubes and ovaries, there is
hope of preventing certain types.1 This involves
elimination or control of what are believed to be causal
agents, a typical examples being the human papilloma
virus (HPV) which is the prime aetiological factor of
cervical cancer.2 Screening modalities in the
developed world constituted a great step in the
prevention of cervical cancer by over 80%.3 The
advent of cervical cancer vaccination revolutionized
the prevention of cancer of the cervix.4 However, there
is scarcity of cervical cancer vaccines in the
developing countries of the world.5 Where these
vaccines are available the cost is a challenge because
majority of the masses cannot afford them.6
Vulvectomy for dysplasia of the vulva epithelium
has its place but does not always prevent squamous
cell carcinoma in that site.7 Hysterectomy for all
women showing cervical epithelial dysplasia or
suffering from post menopausal bleeding or discharge
or whose family is completed could well reduce the
number of cancer if it is cervical cancer or cancer of
the corpus uteri.8 Such an approach, however, is likely
to involve operative mordalities.9
Reason and safety impose strict limit on the
place of prophylactic surgery in the prevention of
cancer of the vulva, cervix, corpus uteri, fallopian tubes
and ovaries.10
Early Diagnosis
It is generally accepted that an early cancer is
more amenable to cure than one which has been
present for sometimes.11 It is important to pay heed to
the first suspicious symptoms or signs presented by
the patient, for example, irregular uterine bleeding or
discharge occurring after the age of forty years.12
Although early diagnosis and treatment must offer the
patient a better chance of survival, they do not always
make much difference that might be expected.1,12
Stage 1 cases of cancer of the cervix can do badly
while more advanced ones sometimes respond well to
treatment.13 This is because certain cancer cell growth
divide the vascular channel at a very early stage,
whereas others can come to terms with their cancer
cells,14 even to the extent of inactivating the malignant
cells liberated into the blood or lodged in the bone
marrow. 15 The first type is rarely cured no matter how
early the occurrence, whereas the second is nearly
always cured no matter how long treatment is
deferred. 14
The result of therapy according to the stage of
cancer of the cervix clearly shows that the less the
clinical extent of the disease the better the outlook.12-14
However, it is often assumed that the extent of a
cancer represents its age.13 That this is not the case
as shown by some literatures that women who have

Kalio et al / Greener Journal of Medical Sciences 13
symptom for more than 6 months before being treated
often show better 5year survival rate than those with
symptoms for only 3 - 6months.12,13
This is because those women who delay taking
advice either die before treatment is instituted or they
have cancers which are only slowly progressive. 5-7
This also explains why the clinical stage of cancer of
the cervix is not necessarily proportional to the
duration of symptoms.14-15
Nevertheless, the earlier the patient reports, the
better the overall 5year survival rate.2,3 Even this
argument, however, may be deceptive. Hypothetically
a woman with a stage 1 carcinoma of the cervix is
treated in 1989 and dies in 1999, her survival for more
than 5years is then credited to early treatment. If the
same woman neglects her symptoms and fails to take
advice until 1994, the cancer has then progressed to
stage iv. She is then treated but only survives until
1995, and thus attributed to her late stage disease. 5-7
The above scenario is hypothetical. Evidence
have shown that microscopically diagnosed cancer of
the cervix at well women clinic who receive prompt
treatment have better prognosis.8,9
PROPAGANDA AND EDUCATION OF THE PUBLIC
Women are often slow to report symptoms of
genital tract malignancies in developed countries of the
world.1-4 The reasons for late presentations of genital
tract malignancies are social, cultural, religious and
economically. 7,8 For this reason, those who believe
that early treatment will have a dramatic effect in the
results often advocate for propaganda to ensure that
all women are aware of the early symptoms of genital
tract malignancies.5,6 Unfortunately some women are
resistant to education by the mass media and are
more likely to accept what they are told by friends than
by the doctors. Often it is the over anxious woman who
takes notice of misinformation and wrong advice,
which have no basis except fear. The women with
genuine symptoms often avoid presenting early. They
would rather remain in doubt because whatever they
may have heard, the refuse to accept that genital tract
cancer can be cured.9
Despite the acknowledged risks of smoking and
genital tract malignancies, 4 young women are
amongst the heaviest smokers in the developed
countries. 7,8 Genital tract malignancies have increased
in women in the past decades.10 To date, health
education does not appear to have been heeded,
although there have been sure reduction in those who
smoke during pregnancy.9 However, in the developed
countries patients with genital tract malignancies
present early compared with developing countries of
the world.4
In developing countries it is commonly observed
especially in the lower socio-economic patients, that
post-menopausal women are reluctant to report
symptoms of abnormal vaginal bleeding and offensive
vaginal discharge to their families because of
embarrassment, although they recognize that these
symptoms are abnormal. 9,10
ROUTINE MEDICAL EXAMINATION
One possible method of improving the outcome
of genital tract malignancy is to discover malignant
disease before it has become invasive or while it is
still microscopic and asymptomatic.3,4 This means the
routine screening of all apparently normal women who
are at risk of genital tract malignancy is
recommended.5 Arrangements for this, however,
usually concentrate on the detection of cervical cancer
to the exclusion of other genital tract malignancies
which may be equally, if not more, injurious to the
health of women. 6,7
In the developed world, cancer of the breast
kills more women compared to cancer of the cervix. 12
It can be argued that regular examination of breast is
as routine as test on the cervix. 12 Malignant conditions
of the ovary, although less common are mostly fatal
unless detected in their early asymptomatic stage.1,4
Again, diseases such as chronic hypertension,
diabetes mellitus, obesity and peptic ulcer disease
may potentially be far more dangerous to women than
is cervical intraepithelial neoplasia.13
Note the observation that cancer detection clinic
or clinics devoted only to clinical or routine cervical
cancer diagnosis are of limited valve.12 If the best
results are to be obtained cervical smears need to be
taken as seriously as a full pelvis and general
examination carried out by someone who is competent
to recognize pelvic and other disease by their clinical
expertise and to give expert medical advice.11-12
From the standpoint of detecting genital cancer
in its early and pre-invasive stage, cytology and
colposcopy have proven their worth. 1,2CA 125 has
been developed as a reasonably satisfactory tumor
marker for ovarian cancer which helps in the
screening, treatment and prognostic factor of cancer of
the ovary.14 However, it is neither cost-effective
method for widespread screening nor is it sufficiently
specific.1,14 Similarly, trans-vaginal ultrasound may be
useful as a screening tool for ovarian malignancy but
not suitable for large scale screening.14
CYTODIAGNOSIS
Cytodiagnosis depends on the fact that epithelial
cells are being shed continually from the epithelial
lining of the genital tract.15 They can therefore be
collected and examined to see if they show cytological
evidence of dysplasa.15 It should be however noted
that cytology is not in itself a method for cancer
diagnosis in general.14,15 It is a means of screening
apparently healthy and symptom-free women to
discover those who deserve further investigation to
see if they have malignant disease.15,16 Cancer can
only be diagnosed with reasonable certainly by
histological examination of malignant tissues.14-16
TECHNIQUES
Vaginal Cystoscopy
The secretory lining of the upper vagina
normally contains desquamated cells from the vaginal

14 Kalio et al / Greener Journal of Medical Sciences
wall.2,3 The vaginal aspect of the cervix, the
endocervix, the endometrium and sometimes the
fallopian tubes are made up of similar epitheliai
tissues.2-4 The examination of desquamated cells in
the vaginal pool, test suggested by George
Papanicolaou may be the earliest means of detecting
premalignant lesions of the genital tract in these cities
especially in the cervix and the endometrium.2,13
This method of collecting material has the
advantage that it can be done blindly by anyone even
the woman herself. Since the smear contains
endometrial as well as cervix cells, its examination
may give lead to cancer in either site.13-15 On the other
hand, the admixture of cells means that the Cytologist
may find it more difficult and time consuming to
interpret .14,15 Since it is the detection of cervical pre-
invasive cells, the cervical scrape method for obtaining
materials is preferable.2,13
CERVICAL SCRAPE
This method is the gold standard of
cytodiagnosis of premalignant lesions of the cervix.12,13
It involves scraping of the superficial cells from the
external and endocervix by means of a special wooden
spatula.16 Accurate application of the spatula to the
squamo-columnar epithelial junction throughout
circumferentially is essential. 14-16
The Ayre’s scrape technique is unreliable in
picking up edometrial cells but it is more efficient than
the Papanicolaou method in collecting cervical cells.17
Moreover, the resulting smear can be assessed more
easily and more quickly in the laboratory.15-17
The Ayre’s spatula occasionally yields
insufficient number of endocervical cells.14-16 The
extended tip spatula with a longer endocervical limb
has been found to have a higher rate of satisfactory
smears.16,17 The Ayre’s spatula can sometimes be
replaced by the cyto-brush to improve the yield of
endocervical cells.18
This is the technique to be employed for the
routine screening of apparently well women.14,15 It can
be applied during pregnancy and is not ruled out if the
woman is menstruating or bleeding .15,16
Indeed it is potentially dangerous to insert
instruments into the cavity of the endometrium if there
is a possibility of cancer of the endometrium with
pyometra. 18 Suction curettage is effective method of
obtaining endometrical tissue using a negative
pressure.18 Suction aspiration of the endometrium
carries an accuracy rate over 80% in the diagnosis of
endometrial cancer.16-18
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Cite this Article: Kalio DGB; Eli S; Briggs NCT; Iwo-
Amah R; Okagua KE (2020). Prevention of Genital Tract
Malignancies: A Task for all. Greener Journal of Medical
Sciences, 10(1): 12-14.